Journal of Trauma & Orthopaedics - Vol 11 / Iss 4 by British Orthopaedic Association

Journal of Trauma and Orthopaedics Volume 11 | Issue 04 | December 2023 | The Journal of the British Orthopaedic Association | boa.ac.uk

Demystifying pain Turning a new phage on bone and joint infections p22

The history of surgery in the treatment of traumatic brachial plexus injuries p26

Why things hurt? Shifting the paradigm on chronic pain p46

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Journal of Trauma and Orthopaedics

Contents

In this issue... 3 From the Executive Editor

32 Features:

How should we introduce new technologies into surgical practice? Part 2: Collaborative data, the role of randomised trials and emerging approaches Chetan Khatri, Stephen Gwilym, Keith Tucker, Edward T Davis, Xavier L Griffin, David Beard and Andrew Metcalfe

Deborah Eastwood

5 From the President Simon Hodkinson

6-7 BOA Latest News 16 News: BOA New Trustees (2024-2026)

18 News: The 2023 Presidential Merit Award

20 Features:

Conflict surgery in Ukraine Dmitry Iershov, Oleksander Zarytskyi, Anton Chornenky and Deepa Bose

22 Features:

Turning a new phage on bone and joint infections Joshua D Jones, Samantha Downie, John Dunn, Graeme Nicol and Daniela Munteanu

26 Features:

The history of surgery in the treatment of traumatic brachial plexus injuries Tom J H Quick

Journal of Trauma and Orthopaedics

Volume 08 Issue 04

Volume 08 | Issue 04 | December 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

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.

2020 NICE Guidelines: Virtual Learning – key recommendations p22 Moving Forward p38

Journal of Trauma and Orthopaedics Volume 08 | Issue 03 | September 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

Amputation in the context of tumour or infection p57

Journal of Trauma and Orthopaedics Volume 08 | Issue 02 | June 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

Journal of Trauma and Orthopaedics Volume 08 | Issue 01 | March 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

A Surgical Day Begins*

Don’t let a fracture obscure the bigger picture Reflections of a Training Programme Director p28

FFN UK Orthogeriatric medicine p52

Rib fracture management in the older adult p54

Volume 08 Issue 03

Training in orthopaedics: Non-accidental injury in COVID-19: My experience The show must go on p12 children during COVID-19 p14 of testing positive p16

Volume 08 Issue 02

*From the editor p03

NOA – Improving quality in orthopaedic care p29

36 Features:

Factors affecting the supply of medical devices to the NHS Richard Devereaux-Phillips

38 Trainee:

Culture and diversity within orthopaedics: What have we accomplished and where are we going? Kate V Atkinson, Zahra Jaffry, Karen Chui, Marieta Franklin, Kriti Singhania, Oliver Adebayo and Abhinav Singh

42 Medico-legal:

Intra-operative breakage of instrumentation during orthopaedic surgery Shyam Kumar and Simon Britten

46 Subspecialty:

Why things hurt? Shifting the paradigm on chronic pain Shefali Kadambande

48 Subspecialty:

Why does it hurt? An overview of pain mechanisms Neeraj Saxena

52 Subspecialty: Complex regional pain syndrome (CRPS) Sunil Dasari

56 Subspecialty: Chronic postsurgical pain:

An inevitable consequence of surgery or preventable disease? Edward Keevil

59 In Memoriam:

Richard Montgomery Asif Saifuddin

Download the App The Journal of Trauma and Orthopaedics (JTO) is the official publication of the British Orthopaedic Association (BOA). It is the only publication that reaches T&O surgeons throughout the UK and every BOA member worldwide. The journal is also now available to everyone around the world via the JTO App. Read the latest issue and past issues on the go, with an advanced search function to enable easy access to all content. Available at the Apple App Store and GooglePlay – search for JTO @ BOA.

Improving the undergraduate T&O experience p32

Volume 08 Issue 01

We are committed to sustainable forest management and this publication is printed by Buxton Press who are certified to ISO14001:2015 Standards (Environmental Management System). Buxton prints only with 100% vegetable based inks and uses alcohol free printing solutions, eliminating volatile organic compounds as well as ozone damaging emissions.

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Medical

KNOW YOUR PATIENT – AND REDUCE PJI RISK

IMPROVED OUTCOMES IN HIGH RISK PATIENTS1 Using dual antibiotic-loaded bone cement as part of set of measures2 in a risk adaptive approach

www.heraeus-medical.com 1. Berberich CE, Josse J, Laurent F, Ferry T. Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence. World J Orthop. 2021;12(3):119-128. doi:10.5312/wjo.v12.i3.119 I 2. Parvizi J, Shohat N, Gehrke T. Prevention of periprosthetic joint infection: new guidelines. Bone Joint J. 2017;99-B(4 Supple B):3-10. doi:10.1302/0301-620X.99B4.BJJ-2016-1212.R1 I 3. Sanz-Ruiz P, Berberich C. Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Center in Spain. Orthop Res Rev. 2020;12:89-96. doi:10.2147/ORR.S256211 I 4. Sprowson AP, Jensen C, Chambers S, et al. The use of high-dose dualimpregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip: The Fractured Hip Infection trial. Bone Joint J. 2016;98-B(11):1534-1541. doi:10.1302/0301-620X.98B11.34693 I 5. Sanz-Ruiz P, Matas-Diez JA, Villanueva-Martinez M, Santos-Vaquinha Blanco AD, Vaquero J. Is Dual Antibiotic-Loaded Bone Cement More Effective and Cost-Efficient Than a Single Antibiotic-Loaded Bone Cement to Reduce the Risk of Prosthetic Joint Infection in Aseptic Revision Knee Arthroplasty? J Arthroplasty. 2020;35(12):3724-3729. doi:10.1016/j.arth.2020.06.045

11915 CZ

Elective primary hip and knee arthroplasty3 Trauma (FNOF)4 Aseptic revision TKA5

Credits

JTO Editorial Team

BOA Staff

Deborah Eastwood (Executive Editor)

Hiro Tanaka (Editor)

Simon Britten (Medico-legal Editor)

Chief Operating Officer - Justine Clarke

Abhinav Singh (Trainee Editor)

Personal Assistant to the Executive - Celia Jones

Shefali Kadambande (Guest Editor)

Education Advisor - Lisa Hadfield-Law

BOA Executive l

Simon Hodkinson (President)

Deborah Eastwood (Immediate Past President)

Mark Bowditch (Vice President)

Fergal Monsell (Honorary Secretary & Vice President Elect)

Ian McNab (Honorary Treasurer)

John Skinner (Appointed Trustee)

BOA Elected Trustees l

Simon Hodkinson (President)

Deborah Eastwood (Immediate Past President)

Mark Bowditch (Vice President)

Fergal Monsell (Honorary Secretary & Vice President Elect)

Executive Office

Policy and Programmes Head of Policy and Public Affairs

- Gary Robjent

Head of Education and Programmes

- Alice Coburn

Programme and Committees Officer

- Eliza Heng

Educational Programmes Assistant

- Maimuna May

Communications and Operations Director of Communications and Operations

- Annette Heninger

Marketing and Communications Officer

- Pujarini Nadaf

Membership and Governance Officer

- Natasha Wainwright

Interim Membership and Governance Officer

- Jamie Gould

Ian McNab (Honorary Treasurer)

Fares Haddad

Amar Rangan

Sarah Stapley

Hiro Tanaka

Finance

Cheryl Baldwick

Director of Finance - Liz Fry

Deepa Bose Caroline Hing

Finance Assistant - Hayley Ly

l l

Andrew Price

Andrew Manktelow

Andrea Sott

Paul Banaszkiewicz

Events Coordinator - Venease Morgan

Stephen Eastaugh-Waring

UKSSB Executive Assistant - Henry Dodds

Publications and Web Officer

- Nick Dunwell

Events and Specialist Societies Head of Events - Charlie Silva

Advertising

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: 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

Disclaimer

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

BOA contact details

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

How to contact JTO Email: jto@boa.ac.uk

From the Executive Editor Deborah Eastwood

s another year comes to an end, it is upsetting to see how many troubled areas there are in our world at present with so much suffering. The recent difficulties in the Middle East are truly saddening and have understandably become front page news – but the Ukrainian crisis continues unabated and the article by our colleagues on Conflict Surgery in the Ukraine (p20-21) highlights how quickly changes can be made when they have to be made, bringing back reflections of the COVID-19 Lockdown changes in healthcare delivery. The article emphasises the need to learn, and to learn quickly, and that all experiences should be used as learning experiences. In Liverpool, it was my privilege to award the 2023 Presidential Merit award to a team: the team who arranged and delivered a series of webinars to help and to educate colleagues in conflict zones. A pertinent reminder that the practice of orthopaedics and trauma is a team sport. The team is diverse and BOTA and the BOA have made huge strides over recent years to change the face of T&O as shown in the article on p38-41. The authors represent the diverse mix that is our future. The future is definitely bright. One of the many reasons I enjoying reading the JTO, is its mix of reflection on times past and descriptions of future initiatives and this edition is no different. Tom Quick reminds us of the history of peripheral nerve surgery (p26-30) whilst on p22-24, Joshua Jones and his colleagues invite us to consider turning the ‘phage’ on a new era for the management of bone and joint infection. Chetan Khatri and colleagues continue their theme on delivering innovation and embedding new technologies in surgical practice (p32-34) whilst on p36-37 Richard Deveraux-Phillips asks us to rethink our relationship with bodies involved in not only the regulation of products but also the supply chain that delivers them to our hands. Our subspecialty section this time goes to the heart of why we are T&O specialists – we like fixing things and making them better but all too often we find ourselves still unable to answer the basic question of ‘why does it hurt, doctor?’ This collection of articles (p46-58) describes some of the advances that have been made in understanding the problem and to structure our commitment to the relief of pain: again teamwork is at the heart of patient care. It is has been a difficult year in terms of the loss of colleagues who are gone ‘too soon’ and personally, the reflections on lives well lived for two colleagues, one at the RNOH and one from BSCOS (p59), remind me to take at least a small step back, look at life with a clear eye and enjoy the time we have together. May I take this opportunity to wish you Season’s Greetings with the sincere hope that you will all be able to spend valuable time with friends and family and take the opportunity to remind each other of how important such connections are. n

From the President

Greetings from down under Simon Hodkinson

welcome you all to this edition of the JTO and to my first piece as President. Currently, I am in Australia having attended the Annual Scientific Meetings of the New Zealand and Australian Orthopaedic Associations. Both meetings have been excellent, and the Australian meeting had a focus on rural medicine. Whilst we have nothing on the scale of the Australian issues in terms of distances for our patients to travel, we do have significant issues when it comes to access to health care for our patients. Recently, Sir Chris Whitty highlighted the issues of our ageing population, with the isolation of the older generation in coastal regions, while the young head for the cities. He and others have highlighted the issues of ill health in the older generation with huge differences in the survival of the richest and poorest of our society. The cost of dying from a preventable or treatable disease is estimated to cost the Exchequer £8 billion a year, with the cost of lost output due to ill health in the working age population estimated to cost £150 billion a year. Given that it is estimated that 20 million of our population has some form of musculoskeletal problem, this puts the ball firmly in our court. We are living longer but not healthier, and we need to reduce the time our population spends in ill health. All the while our waiting lists grow and as such the BOA in November has written to the Chancellor and the Prime Minister to support the £1 billion requested by NHS England. All too often when winter pressures strike, which seem to be earlier and earlier, the immediate response is to stop planned T&O care, so it is essential that planned elective orthopaedic care continues this winter uninterrupted. The workforce will be my focus this year and whilst ‘down under’ it has been interesting to meet and talk to several UK trainees who have left our shores. Australia trains about 3,000 doctors a year but imports a further 3,000 and is still short of workforce. At home, the General Medical Council has confirmed that in 2022, 2,000 UK trained doctors left the United Kingdom to pursue their careers elsewhere. This echoes the findings of the recent medical student survey which reported that one third of those surveyed intended to leave after F2 and half of these did not intend to return. These figures show we are haemorrhaging our own trained workforce, which is clearly not sustainable, and recently the GMC highlighted that even with the proposed doubling of medical school places, which is to be commended, this increase in workforce will not be available in the immediate future. It is therefore even more important that we sustain and retain what we have, and I will be lobbying all to focus on this issue. Our young colleagues have an eminently portable qualification and are clearly attractive to others! On a brighter note, we have made strides in connecting with the MHRA and NHS Supply Chain on the issues of implants and the problems of the Medical Device Regulation and we have been asked to work with NHS England / GIRFT on a revamp of coding to support the introduction of the Medical Device Outcome Registry (MDOR) and improving data collection. Hopefully if all goes to plan this will improve our lives and benefit our patients. This edition has some excellent articles which I hope will be of interest to all. I wish you all a very restful Christmas and a happy New Year. n

Latest News

AGM Update

2024 BOA Medical Student Essay Prize

We are pleased to announce that all resolutions presented at the AGM have passed with a majority vote. To summarise:

The BOA are pleased to announce that for 2024, a prize will be awarded for the best Quality Improvement Project: “Have you found a better way of doing something in orthopaedics? Then we want to hear from you. Tell us about your Quality Improvement Project (QUIP) and how it has equipped you and your department to perform better. The project must have completed at least one round of the Plan Do Study Act (PDSA) cycle and can be on any aspect of T&O - from education to patient preparation or adoption of surgical innovation.”

• All voting members will be eligible to stand for election to Trustee posts on the BOA Council; • All candidates standing for election as an Officer must have previously been a Trustee and served one full term on the BOA Council; and • All elections will be run using the same format of single transferable vote.

Submissions will open on February 1st 2024. Further information on the BOA Medical Student Essay Prize can be found at www.boa.ac.uk/medical-student-essay.

All voting members can now vote at the election of President, Honorary Treasurer and Honorary Secretary. Further details are on the website: www.boa.ac.uk/AGM.

Congratulations to Sumedh Sridhar, winner of the 2023 Medical Student Essay Prize. Their winning essay is featured on page 08.

Get involved in UKITE BOA Ortho Update 2024 Saturday 6th January - 8:30AM - 5:00PM, Manchester This one day course will give delegates the opportunity to access new understanding and support preparation for the FRCS exam. We will provide the facility for delegates to participate in Case Based Discussions (CBDs), Practical Simulation sessions and new for 2024 Exams and Clinical Examination sessions across a range of critical condition topics, delivered by expert clinicians. Real FRCS examiners will talk about how the exam is conducted and scored, along with some top tips for preparing and passing.

More than 800 trainees from across the UK and Ireland are expected to take the UKITE Exam online between the 9th and 15th December. Since its inception in 2007, UKITE has helped trainees prepare for section 1 of the FRCS Tr and Orth with questions covering the full spectrum of sub-specialties, contributed by our volunteers. We would like to thank our tireless team of editors, subspecialty leads, and our clinical leads, Ajay Malviya and Mark Sohatee for their tireless work. Our editors make UKITE possible by developing, reviewing and validating questions.

This year’s critical condition CBDs will cover diabetic foot and the ‘foot attack’, cauda equina syndrome, and the painful paediatric hip and spine. There will also be a return of the brilliant quick-fire trauma meeting called ‘The Good, the Bad and the Ugly’ which will look at basic science of trauma, biomechanics and complications.

We have vacancies in all sub-specialties for senior trainees, SAS, or new consultants who can contribute an hour or two per month. This is great introduction to question writing and examining, no experience required, we provide all the training. Find out how to join the team at www.boa.ac.uk/UKITE-editorial-role.

To view the updated programme and book your place visit www.boa.ac.uk/OrthoUpdate for more information and how to register.

For any queries, please contact ukite@boa.ac.uk or visit www.boa.ac.uk/UKITE.

Addendum to ‘Blowing against the wind’, JTO Vol. 11, Issue 3 In the article ‘Blowing against the wind: the case for shifting the current paradigm on theatre ventilation’, page 54-55 of September’s JTO, it was suggested that the Lidwell paper was widely criticised for lack of controls of the variables and uncontrolled use of peri-operative prophylactic antibiotics. The original 1982 BMJ paper did not contain a multivariate analysis, for the simple reason that the software to do it did not exist at that time. Data held in the National Archives shows that Dr Lidwell was well aware of this problem and he made sure that his retirement was delayed until the multivariate analysis had been carried out. The trial data was retained and analysed when the MRC purchased the multivariate analysis software, which they did as soon as it became available. The multivariate analysis (Lidwell 1984) showed that the effect of the ultraclean area was independent of the use of antibiotics. We applaud the dedication of Dr Lidwell and his colleagues and the impact that it has had on our profession. The controversies discussed in the article are informative and do not reflect any changes in the BOA’s support for the use of ultraclean theatres in trauma and orthopaedic surgery.

Acute Management of PeriProsthetic Joint Infection BOAST The BOA have recently published a new Trauma BOAST (BOA Standard) on Acute Management of Peri-prosthetic Joint Infection (PJI). PJI can present with life threatening sepsis and immediate recognition and resuscitation is essential. Recommendations on antibiotic prescribing, orthopaedic referral and assessment are outlined in this new BOAST. You can read the full BOAST at: www.boa.ac.uk/acute-management-of-PJI. A full list of BOASTs can be found on the BOA website at www.boa.ac.uk/BOASTs.

News

2023 BOA Medical Student Essay Prize Winner

ongratulations to Sumedh Sridhar, winner of the 2023 Medical Student Essay prize for his essay on ‘Bones, burnout, and beyond’: Strategies for supporting T&O staff and patients in a changing landscape’. Sumedh Sridhar is a final-year medical student studying at the University of Leicester. With a passion for medical education, he’s been the driving force behind several academic initiatives, such as the rapidly growing OsceAce website. He’s also worked with notable organisations, such as OSCER, PassMedicine, Elsevier, and the Shout Crisis Line. Sumedh’s dedication and hard work have earned him recognition, including a collection of local and national prizes. As he approaches the end of medical school, Sumedh has his sights set on a future in either surgery or paediatrics.

Essay Summary In recent years, T&O has experienced significant changes in patient and staff demographics, accelerated by the COVID-19 pandemic. Failure to combat worsening staff retention rates and increasingly medically complex patients will hinder our ability to arise to the healthcare challenges of tomorrow. According to the Office for National Statistics, there will be an additional 7.5 million people over the age of 65 living in the UK by 2069. Predictive models suggest 68% of this 65+ population will be multi-morbid. Consequently, already overburdened services will face increasing demand from a population suffering from orthopaedic pathology for a greater proportion of their lives. Public health initiatives targeting preventable pathology such as obesity and falls prevention programs would be invaluable in reducing future caseloads. T&O staff face the highest number of patients waiting for treatment, high burnout rates, reduced morale, and consequently an anticipated

shortage of senior staff in the future. Burnout recognition programs, on-site mental health support, and adopting a more open culture when discussing burnout would be beneficial in preserving the workforce. Anonymised research was conducted to better understand the perspectives of staff. A survey of 20 orthopaedic staff at Kettering General Hospital revealed increased workload and poor recognition of staff efforts were the main issues which needed to be addressed. An NHS internal rewards system and technological advancements to improve efficiency are potential solutions to these issues. Similarly, a survey of 50 medical students revealed mentoring programs for juniors as the most important issue to address. This reassuringly demonstrates that students recognise the issues at hand but feel that they can be addressed through greater support networks. In summary, a multi-faceted approach to ensure that the workforce of today is well equipped to deal with the challenges of tomorrow. You can read Sumedh’s winning essay on Orthopaedics Online at www.boa.ac.uk/O2 where we will be featuring the highest ranked essays throughout December. n

News

BOA / Zimmer Biomet sponsored travelling fellowship Caroline Dover

undertook my fellowship in the Shoulder and Elbow department in La Paz University Hospital, Madrid, under the guidance of Dr Samuel Antuña. During my visit, I attended clinics on a daily basis, observing cases of proximal humeral and humeral shaft fractures, septic arthritis to the shoulder, and complex elbow and distal humeral fractures. The clinics were also an opportunity for the team to gather information for current research, and Dr Antuña demonstrated Distension Test in Passive External Rotation (DTPER), and we were able to discuss their validation study1. It was interesting to compare our preferred management for new referrals, e.g. management of distal radius fractures. A recent BOAST2 reports good outcomes in patients over 70 years of age with distal dorsal displacement. Some members of the Spanish team still choose to offer surgery in the vast majority of patients, regardless of age or direction of displacement, and repeat radiographs in those managed conservatively, at the time of plaster removal (five-six weeks). In elective theatres, the team use implant planning software for the planning and delivery of inverse shoulder replacements, with glenoid navigation utilised in all patients. Although slightly more time-consuming, the technology did provide reassurance regarding contact of the glenoid baseplate, and I can see the benefit in patients where this is of particular concern.

One surgical technique that I found particularly interesting was the use of the Galaxy External Fixator for the management of proximal humeral fractures. The vast majority of my experience so far, with regards to external fixators for the upper limb, has been in the context of open fractures, poly-trauma and patients with vascular injury. In my hosting hospital, this system is routinely used for the management of proximal humeral fractures. Advantages reported include reduced soft tissue damage and disruption to the blood supply of the proximal humerus, with improved post-operative mobilisation, and the benefit of avoiding long-term metalwork implantation. The external fixator device remains in situ for four weeks, and I witnessed patients at day one following surgery mobilising the shoulder, elbow and wrist, with good contraction of the deltoid clinically. Placement of the pins has previously been safely described in the literature3. I am incredibly grateful to Dr Antuña and his team, and to the BOA and Zimmer Biomet for providing me with this incredible opportunity. 1. Noboa E, et al. Distension test in passive external rotation: Validation of a new clinical test for the early diagnosis of shoulder adhesive capsulitis. Rev Esp Cir Ortop Traumatol. 2015;59(5),354-9. 2. BOAST - The Management of Distal Radial Fractures. BOA 2017: www.boa.ac.uk/resources/ boast-16-pdf.html. 3. D’Ambrosi R, et al. A prospective study for the treatment of proximal humeral fractures with the Galaxy Fixation System. Musculoskelet Surg. 2017;101(1), 11–7. n

Combined Services Orthopaedic Society (CSOS) Update Surg Lt Cdr Philippa Bennett, CSOS Honorary Secretary

xford hosted our 2023 meeting with all elements held in the incredible Keble College. Delegates made the most of the world-class lecture facilities, onsite accommodation and the fabulous gothic dining hall for a truly memorable conference. The theme of the instructional day was surgical support to operations. A review of doctrine preceded an opportunity to examine the instrument sets available on deployment. Finally, a lecture on pelvic and acetabular injuries was followed by a practical on pelvic external fixators. The academic day combined research presentations with keynote addresses from leaders in our specialty and the Defence Medical Services. Bob Handley, Professor Matt Costa and the Surgeon General, Maj Gen Tim Hodgetts, provided fascinating reflections and insights on the development and future direction of trauma care, both within the military and across the wider NHS. Surg Lt Jonathan Edwards won the best podium presentation for his comparison of virtual reality and conventional training for scrub nurses learning tibial nailing; Surg Lt Cdr Liam Kilbane will go forward to Congress for Best of the Best. Yousra Jamal and Capt Abigail Bainbridge were highly commended for their presentations.

In 2024 the Society will mark its 50th Anniversary: a two-day meeting will be hosted at the National Army Museum, London with the Mess Dinner at the Royal Hospital Chelsea. We hope as many members as possible can join us for the occasion: those who are not currently receiving society communications are invited to contact the Secretary for further information: secretary@csos.org.uk. n

News

British Association for Surgery of the Knee (BASK) update Leela Biant, BASK President and James Murray, BASK Honorary Secretary

ASK returned to London under the Presidency of Professor Leela Biant, for a fantastic meeting in Westminster in May – even the sun came out! The meeting had some contributions from the Combined Orthopaedic Societies of South Africa, New Zealand and Australia, keeping this important link going. Whilst there was a stellar cast of speakers from across the UK and more globally, Professor Antonia Chen gave a truly expert Lorden Trickey Lecture on Outcomes in Revision Knee Surgery, following a sharp 10 Key Principles of Management of Knee Prosthetic Joint Infection. The BASK executive are truly grateful for the excellent support from BASK members and the Industry making this spring meeting the biggest BASK Congress yet. Thankfully, the feedback matched and there is no doubt it was a popular meeting. We received some suggestions too and will try to add these in for the forthcoming meetings which are travelling around the UK:

• 2024 May 21-22 Manchester Central Convention Complex • 2025 April 29-30 Harrogate Convention Centre • 2026 April 14-15 Glasgow Scottish Events Campus The BOA was in Liverpool in September and BASK ran two educational sessions including a fascinating Adrian Henry from Professor Gareth Scott on ‘How the Knee Moves’ and then a thought-provoking lecture on ‘Burnout’ by Professor Paul Barach. October saw the 2nd BASK Revision Knee Course in Edgbaston with a fantastic turnout from

both revision units and major revision centres. The UK revision knee network has really taken off and BASK has committed funding to support this with the development of an app to work out the RKCC grading as the British Hip Society did for the RHCC grading system. The app is now in prototype and will hopefully be live by the spring Congress in 2024. In a similar vein the commissioned UK cartilage surgery hospitals have been notified and this will hopefully develop the national network for the treatment of cartilage defects. BASK has continued to voice concerns of knee surgeons within the framework of the NJR, ODEP and Beyond Compliance. This issue has been particularly active this year in light of camouflage (hiding poor results of a prosthesis diluted in the generally good results of a ‘family’ of prostheses with the same name). BASK encourages members to re-check the ODEP rating of the EXACT combination of implants being used in their institution, and to insist clinical considerations are paramount in procurement decisions. We look forward to welcoming you to Manchester in May 2024! n

The British Orthopaedic Research Society (BORS) update Wasim Khan, BORS Honorary Secretary

he British Orthopaedic Research Society (BORS) is a multidisciplinary association founded over 60 years ago, in 1961, devoted to pursuing research relevant to orthopaedic and musculoskeletal surgery. Unlike most of the 22 BOA affiliated Specialist Societies, it benefits from a more diverse membership including surgeons, scientists, engineers and vets as well as allied health care professionals. The research interests of its membership are varied and include: Biological Science, Biomechanics, Osteo-articular Pathology, Biotribology, Molecular Biology, Bioengineering, Medical Imaging, and Patient Management. After a successful joint meeting of the International Combined Orthopaedic Research Societies (ICORS) last year, the 2023 BORS Annual Meeting was held at St John’s College, University of Cambridge on 25th – 26th September with over 100 attendees.

The Presidential Lecture was delivered by Professor Niamh Nowlan (Dublin). There were other keynote speeches by Professor Gordon Blunn (Portsmouth) on biomechanics, Dr Jennifer Paxon (Edinburgh) on tissue engineering, and Professor Xavier Griffin (London) on clinical trials. Sessions from OATech and Versus Arthritis (VA) saw several talks and a roundtable discussion. There were also a number of free paper sessions on biomechanics and biology, as well as rapid oral poster presentations that were very well received. BORS and BJR sponsor a travelling fellowship every other year that allows two clinicians, two biologists and two engineers to travel together to a number of worldrenowned orthopaedic research centres. A BORS / BJR Session highlighted the success of the 2023 Fellowship. The next BORS Meeting will be held in Sheffield on 9th – 10th September 2024, and we look forward to hopefully meeting more of you face-to-face then. n

News

Joint Action Update

Amol Tambe

Joint Action - The Orthopaedic Research Appeal of the BOA We need your help! Musculoskeletal problems impact all sectors of society from children to the elderly with over 20 million people in the UK living with an MSK condition. That’s about a third of the population, with 11 per cent of those affected being under 35. Please support the BOA in helping to make a difference through donating to Joint Action, www.boa.ac.uk/make-a-donation.

Hasan Rahij

Save the Dates and Support! Please support our runners and riders taking part in the TCS London Marathon on Sunday, 21 April 2024, and Prudential RideLondon 100 – Sunday, 26 May 2023, to raise funds for Join Action. Please donate and show your support through JustGiving at: www.justgiving.com/boa. Find out more about Joint Action, The Orthopaedic Research Appeal of the BOA online and the clinical trials we are currently funding, www.boa.ac.uk/clinical-trials.

Alex Chipperfield

News

Deborah Eastwood and Nick Robinson

2023 BOA Congress Review Fergal Monsell, BOA Honorary Secretary

he BOA Annual Congress took place on 19th - 22nd September 2023. We returned to Liverpool ACC, which provided a city centre location with the usual distractions to accommodate a wide variety of extracurricular activities including an inaugural pre-Congress cycling event. There were approximately 2,000 delegates for the main section of the Congress and whilst we are still collating the feedback, early indications are that the event was very well received, and this is due to the herculean efforts of the organising team. The theme was ‘Sustainable Orthopaedic Systems’ and this was punctuated with an excellent scientific programme, which included sessions that discussed the implications of Medical Device Outcome Registry (MDOR) & Cumberledge Report and a lively debate that considered the motion ‘This House Believes that Apprentice Training of Doctors represents the Future’. The importance of broader engagement was recognised with the inclusion of separate sessions dedicated to the Extended Theatre Team and to

medical undergraduates with an interest in orthopaedic surgery as a future career. This included lectures and workshops, in addition to providing interested students with the opportunity to engage in the entire Congress programme. The Presidential guest lecture was delivered by Professor Kristy Weber, who considered ‘The critical role of strategy and governance in professional orthopaedic

of COVID-19 but nevertheless, we were able to combine where necessary and deliver sessions with top quality educational content. Our engagement with industry is fundamentally important to the success of this event and our partners were represented in a conventional exhibition hall in addition to a product theatre and feedback has been very positive. For those who were unable to attend in person or who faced the dilemma of choosing between simultaneous sessions, all content is available on the BOA website and can be viewed at leisure. Congress registrants have exclusive access to this material for a period of three months and following this, it will be made more widely available on a number of digital media outlets. After a short break, we are already planning for the 2024 Congress with the theme being ‘Recruit, Sustain, Retain: The T&O Workforce’, between 17th – 20th September at the ICC Birmingham and we hope you will be able to join us. n

“Our engagement with industry is fundamentally important to the success of this event and our partners were represented in a conventional exhibition hall in addition to a product theatre and feedback has been very positive.”

organisations’. The Howard Steel lecture entitled ‘Why politics is not delivering’ was given by Nick Robinson and the Robert Jones Lecture entitled ‘Innovation, regulation and evaluation in orthopaedic surgery’ was given by Professor Andrew Carr. There was a reduction in the number of free papers, which may be a legacy effect

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Awards and Medals Congratulations to our Congress prize winners! The Presidential Prize for Sustainability was presented to Francesca Solari for their work as part of the BOA/BOTA sustainability project and their presentation ‘Rationalization of orthopaedic surgical instrument trays’. The Best of the Best Certificate went to Alex Woods representing the Oxford Thames Valley region for their presentation ‘Combining Zoology and Surgery – development of a new medical device for nerve repair’. Thomas Baldock was the winner of the Best Poster Prize for their ‘Orthopaedic Trauma Hospital Outcomes Patient Operative Delays (ORTHOPOD) Study’. We extend our congratulations to Helen Cattermole, winner of the Robert Jones essay prize and medal; and Sumedh Sridhar, winner of the medical students’ essay prize. Thank you to all our exhibitors who supported us to help make Congress happen. The winner of the Exhibitors Cup for Best Large The Best of the Best Certificate, Stand was Let’s Talk Doctor and the received by Matthew Costa on Exhibitors Plaque for Best Compact behalf of the winner Alex Woods Stand went to Medbelle. n

Best Poster Prize winner Thomas Baldock

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New BOA Trustees (2024 – 2026) Vikas Khanduja

ikas Khanduja is a Consultant Orthopaedic Surgeon specialising in both sports surgery and arthroplasty aspects of hip surgery at Addenbrooke’s – Cambridge University Hospital. He has been instrumental in setting up the tertiary referral service for young adults with hip pathology in Cambridge for the East of England and leads the service as well. In addition to his clinical practice, he also leads the Cambridge Young Adult Hip research group and is an Affiliated Associate Professor at the University of Cambridge. The focus of the research group is on the use of novel technologies for the assessment and improvement of outcomes in young adults with hip pathology. The group has a strong national and international presence with good collaborative links within Cambridge and abroad. He has authored over 185 peer-reviewed articles and three books. Vikas is the recipient of the Arnott Medal presented by the RCS Eng in 2013, the Hunterian Professorship presented by the RCSEng in 2021, the Armourers and Braisiers Venture Prize in 2022 and the Institute of Physics Lee Lucas Award in 2023. He currently sits on the Executive Board of the British Hip Society as the Immediate Past President, the ESSKA Board as Chair of European Hip Preservation Associates, the SICOT Board as President Elect, ISAKOS as the Associate Editor in Chief of JISAKOS and is the Trustee and Past Chair of the Non Arthroplasty Hip Registry. He has contributed immensely to the orthopaedic community over the past 15 years and wishes to continue to do the same for the BOA especially in the arena of research and use of technology for education. n

Ben Ollivere

en OIIivere is a Clinical Academic Trauma Surgeon (one of just a handful in the UK) working at Nottingham University where he is Professor of Orthopaedic Trauma, Head of Department and Associate Faculty Pro-Vice Chancellor for the faculty of Medicine and Health sciences. He trained in Oxford, London and later Cambridge before coming to Nottingham as a clinician in 2011 and then moving to the University in 2016. He was subsequently appointed to a Chair in 2020. He is a world leader in his field and has achieved significant research funding from the MRC, NIHR and InnovateUK. He takes a big picture approach to research with themes established in injury and recovery, frailty and decline and chest injury. Ben is an experienced surgical and academic educator being an associate fellow of the HFEA. His experience includes leading both MSc modules and undergraduate surgery education and UG curriculum design to meet new GMC requirements. He has eight years experience as Training Programme Director for the East Midlands HST programme. In 2020 he was awarded the national Training Programme Director of the year award. Ben decided to stand for election as a trustee as over the past decade he has been heavily involved in the UK orthopaedic community (as BJ360 Editor, Training Programme Director, clinical trialist and member of various committees). He has seen how valuable the BOA is to us as a community. Ben believes it is essential that the Association represents the interests of its members, current and future as T&O in the UK is special, and the BOA is central to that. n

News

Amar Rangan

mar Rangan is a Shoulder and Elbow Surgeon based at the James Cook University Hospital in Middlesbrough and is Professor of Orthopaedic Surgery, holding the Mary Kinross Trust & Royal College of Surgeons Chair at Department of Health Sciences and Hull York Medical School, University of York. He also holds a full Professorship with the Faculty of Medical Sciences & NDORMS, University of Oxford. Amar is delighted to be re-elected as a BOA Trustee to continue the work he has started in developing a BOA strategy to support BOA members and the Life Sciences industry in introducing, evaluating, and adopting innovations in T&O. Amar brings to the BOA Council his wide-ranging experience and understanding of current issues that face us within T&O in our professional practice, training / education, and research. He has gained that experience from holding leadership roles such as Chair of BOA Research Committee from 2013-2018, President of the British Elbow and Shoulder Society 20192021, the Academic / APOS Representative on the T&O SAC from 2013 to 2016, Surgeon Member of NJR Steering Committee, and he has been FRCS (Tr& Orth) examiner for the Intercollegiate Specialty Boards for 10 years. Amar looks forward to continuing his contributions to the work of the BOA Council in progressing the BOA’s strategic priorities and initiatives. n

New Honorary Secretary Hiro Tanaka

t has been a privilege serving on BOA Council for the past four years. My passion throughout my career has been supporting and training the next generation of surgeons from medical students to our young consultants. If we inspire, nurture, and challenge them in the right environment, I believe they will develop the grit to flourish even in the harsh reality of the current NHS and they will find the courage to lead change. I have been a part of that journey having chaired the Education Committee of the BOA and co-created the Future Leaders Programme. As Honorary Secretary I will continue that vision for a more inclusive, collegiate, and influential Association. In the midst of chaos, there is also opportunity. I believe we are at a critical moment in our profession. Change is inevitable both for us as surgeons and patients. The BOA is the most effective instrument by which the right changes are adopted because it is the combined voice of our consultants, SAS surgeons, trainees and patients. n

“My passion throughout my career has been supporting and training the next generation of surgeons from medical students to our young consultants.”

News

The 2023 Presidential Merit Award

he 2023 Presidential Merit Award was presented to a team including, Fergal Monsell, Bob Handley, Jonathan Hobby, Shehan Hettiaratchy and Andrii Lysak, who have delivered a series of webinars since the conflict in Europe involving Ukraine began and continue to do so. They have worked tirelessly over a prolonged period of time to deliver regular webinars that have helped surgeons and healthcare professionals in resource poor and war-torn countries. The series of webinars has brought together recognised experts with deployment experience, covering a wide range of topics relevant to the management of battlefield trauma. Professor Deborah Eastwood and the BOA are extremely grateful to each winner of this award for their fantastic work in providing this support.

Bob Handley

Shehan Hettiaratchy

Bob Handley has been a Consultant Orthopaedic Trauma Surgeon in Oxford since 1994. He is the GIRFT National Clinical Lead for Orthopaedic Trauma. He is a past President of the BOA, OTS and AOUK&I. When free-range he worked in Shetland, the Falklands and for the British Antarctic Survey. He is now a grandfather and has hens.

Shehan Hettiaratchy is the Major Trauma Director at Imperial College Healthcare NHS Trust and Honorary Clinical Senior Lecturer at Imperial College. He is a Consultant Plastic and Reconstructive Surgeon who specialises in all aspects of hand and wrist surgery and complex extremity reconstruction. He is a Visiting Professor at Anglia Ruskin University.

Fergal Monsell

Jonathan Hobby

Andrii Lysak

Fergal Monsell graduated without distinction from the Welsh National School of Medicine, completing higher surgical training in Manchester and fellowship training in Sydney. He was appointed to the Consultant staff at the Bristol Royal Hospital for Children in 2004 and is involved in the management of paediatric patients with a special interest in limb deformity and trauma.

Jonathan is a Consultant Hand and Orthopaedic Surgeon at the Hampshire Hospitals. He was the President of the British Hand Society in 2022. He was the BSSH Stack travelling fellow in 2009, and an American Society for Surgery of the Hand travelling fellow in 2010. He has been chairman of the BSSH Instructional Courses and is the Chair of the FESSH Education Committee. He is the speciality adviser to GIRFT for hand surgery, and is currently the clinical lead for the Hampshire and Isle of Wight ICS.

Andrii Lysak is a hand and peripheral nerve surgeon specialising in brachial plexus and hand function restoration after complex injuries. In 2020, he passed the European Board for Hand Surgery Examination. Since the beginning of the full-scale war in Ukraine, he has been fully engaged in the treatment of the wounded and put great effort into creating training programmes on these issues.

The recordings of the webinars are available at www.boa.ac.uk/Ukrainewebinars and they have also been made into concise generic videos on battlefield trauma at www.boa. ac.uk/battlefield-trauma including paediatric focussed resources (www.boa.ac.uk/paediatricbattlefield-trauma) which are relevant to the provision of assistance in areas of conflict but independent of geo-political considerations.

News

Conference Listing 2024 BASS (British Association of Spine Surgeons)

BASK (British Association for Surgery of the Knee)

www.spinesurgeons.ac.uk 20-22 February 2024, Bournemouth

www.baskmeeting.com 16-17 May 2024, London

BHS (British Hip Society)

BAJIS (Bone and Joint Infection Society)

www.britishhipsociety.com 28 February - 01 March 2024, Belfast

www.bajis.org.uk 13-14 June 2024, Gateshead

BSCOS (British Society for Children’s Orthopaedic Surgery)

SBPR (Society of Back Pain Research)

www.bscos.org.uk 07-08 March 2024, Leeds

www.sbpr.info 13-14 June 2024, Aberdeen

BOFAS (The British Orthopaedic Foot and Ankle Society)

BOOS (British Orthopaedic Oncology Society)

www.bofas.org.uk 06-08 March 2024, Belfast

www.boos.org.uk 27-28 June 2024, Cardiff

BLRS (British Limb Reconstruction Society)

BORS (British Orthopaedic Research Society)

www.blrsmeeting.com 14-15 March 2024, Glasgow

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Features

Conflict surgery in Ukraine Dmitry Iershov, Oleksander Zarytskyi, Anton Chornenky and Deepa Bose

O Dr Dmitry Iershov graduated from Dnipro Medical Academy in 2007. He has worked for the last seven years as Chief Paediatric Orthopaedic Surgeon in Tsentr Materi Ta Dytyny (Rudnev Multidisciplinary Hospital of Mother and Child) in Dnipro, Ukraine.

Dr Oleksander Zarytskyi studied medicine in Vinnytsia, Ukraine, qualifying in 2016. He started work as an Orthopaedic Surgeon in City Hospital No. 1 in Zhytomyr, Ukraine.

leksander Zarytskyi is a young orthopaedic surgeon who works in a city called Zhytomyr, in central Ukraine. Since 24th February 2022, his practice has changed immeasurably. He says he could not have imagined how enormous that change would be. “I am working in the city hospital, and cases that we considered as extremely complicated for our department, because of lack of experience and theoretical knowledge, now become routine cases.” Many of the combat injuries involve loss of bone and soft tissue, and consequently require specialised techniques and equipment that are not routinely available in Ukrainian hospitals. Dmitry Iershov is a paediatric orthopaedic surgeon who works in the city of Dnipro, which is within 200 miles of many of the major battlegrounds during this war; Mariupol, Donetsk, Kherson, Kharkiv. The city has become a hub for humanitarian activity, and its hospitals act as second line institutions for many of the war wounded who have been evacuated from the front lines. Dmitry says, “Me and my colleagues used to work with children and do elective cases. Nowadays we treat mostly adults with contaminated or infected open fragmentation injuries. It encourages us to become active and curious again. We are fast learners.” Injured military personnel receive emergency care in front line hospitals, after which they are evacuated to second line hospitals for further debridement and stabilisation. Following this, they are sent further away to cities in Western Ukraine such as Vinnytsia and Lviv for reconstruction of their complex injuries. Occasionally, patients who are local to the area will receive the entirety of their treatment in Dnipro. The need to keep the evacuation chain moving is particularly trying for Dmitry, as he is often unable to complete any treatment started in Dnipro.

Apart from the fact that many orthopaedic surgeons are unfamiliar with combat injuries, there are other challenges to be faced. There are not many plastic surgeons in Ukraine, and few who are familiar with trauma. Soft tissue cover of complex injuries is essential, and the lack of these skills results in an increased incidence of chronic osteomyelitis and infected non-unions. There is often limited access to microbiological facilities or advice, which impacts on the ability to manage bone infection effectively. Many external agencies have sought to provide medical aid and training in Ukraine. Among these are UK-Med, the David Nott foundation, and AO. The international orthopaedic community have been galvanised into action, with many nations offering both online training and practical help on the ground. The British Orthopaedic Association ran a series of very well-received webinars in collaboration with the Ukrainian Orthopaedic Association (www.boa.ac.uk/Ukrainewebinars). UK-Med have supported British orthopaedic and plastic surgeons to provide in person training in a number of hospitals.

Critical bone loss following combat injury.

Features

Dr Anton Chornenky graduated from Dnipro Medical Academy in 2019 and is currently in a postgraduate orthopaedic programme in Tsentr Materi Ta Dytyny in Dnipro, Ukraine.

Deepa Bose is a Consultant in orthopaedic trauma and limb reconstruction at the Queen Elizabeth Hospital Birmingham. Her practice is exclusively in adults, and includes general trauma, major trauma and posttraumatic limb reconstruction. She is Chair of the Specialist Advisory Committee for T&O, and the lead for CESR approval process. She is the Past Chair of World Orthopaedic Concern UK, which focuses on teaching orthopaedics in low resource countries. Deepa has been on the Emergency Response Team of UK-Med, a first response team for international disaster relief, since 2012 and regularly participates in humanitarian projects in Guyana, Gaza and Ukraine.

Orthopaedic trainees in Ukraine do not have the kind of structured postgraduate training that we are used to in the UK. They usually complete two to three years in a hospital’s residency programme. Since the start of the war, their learning curve has been exponential. Dmitry says, “Young doctors and residents are placed in extraordinary conditions when they often have to manage severe trauma cases by themselves. This leads to fast professional progression. They usually have to work extra hours daily.” Anton is one of the young surgeons working in Dnipro, and often works for over 24 hours at a stretch. Oleksander mentions that “young surgeons become involved in urgent life-saving surgery, especially those who were mobilised and are working near the front line.” It is not just the trainees who are learning new skills. Many Ukrainian orthopaedic surgeons have had to adapt quickly to the changing circumstances. In addition to the techniques of adequate debridement and stabilisation they are starting to manage critical bone defects, treat infection, and even to perform local flaps to achieve soft tissue cover. The understanding of antibiotic stewardship, a crucially important concept in any country, is growing amongst the medical community.

Cross leg flap after failure of local flap.

I have been on several visits to Ukraine in the last year, and every time I have been in awe of their courage and spirit. Medical staff regularly volunteer to work on the front lines. In the hospitals, work continues well into the night, often on a voluntary basis by those who have already completed a full day’s work. In spite of this, there is humour and good cheer. There is an enviable team spirit amongst the theatre team. Dmitry and Anton say, “We try to support each other with jokes and dream of what we are going to do after our victory.” Ukrainians are quick to acknowledge the support they have received from other countries. “As orthopaedic surgeons we faced a big lack of knowledge on soft tissue reconstruction, but due to help of our foreign colleagues we are filling the gap” remarks Oleksander. Dmitry agrees, “I can’t say how grateful we are to all Europeans who opened their doors and hearts to our children and families.”

The truth, however, is that innovation in our surgical knowledge and skills are driven by war. Our personal and professional growth occurs in times of misfortune. As Dmitry says, “I definitely know now that in extraordinary situations each of us can give more”. Desperate though conditions are, Oleksander says that, “such involvement of young generation of surgeons in limb reconstruction will lead to a heyday of orthoplastic surgery in Ukraine.” One of the most remarkable things that has happened as a consequence of this awful situation has been the coming together of the international orthopaedic community to help and support in any way possible. Whilst it remains my dearest hope that we never have to see another conflict, it has been a source of hope and inspiration to see my fellow orthopaedic surgeons stand shoulder to shoulder with those in need. n

Features

Turning a new phage on bone and joint infections Joshua D Jones*, Samantha Downie*, John Dunn, Graeme Nicol and Daniela Munteanu * Joint first authors

B Dr Josh Jones is the UK’s only NHS Clinical Phage Specialist, currently based in NHS Tayside. He has also previously supported the use of phage therapy in NHS Lothian and NHS Greater Glasgow & Clyde.

Samantha Downie is an ST8 registrar in Tayside. She has subspecialty interests in peri-prosthetic hip infection and trauma and was privileged to be part of the team for this milestone surgical procedure.

acteriophage (phage) therapy shows promise as an adjunctive therapy to antibiotics for difficultto-treat infections. Phages are naturally occurring viruses that infect and kill bacteria, generally in a species or strain specific manner. Phages are found in the environment wherever bacteria exist, from sewage to skin. With an estimated 1031 phages on the planet, they are collectively the most abundant biological entity on Earth1. Lytic phages have a relatively simple replication cycle. A phage particle binds the surface of a target bacterial cell and the phage’s genetic material is ‘injected’ into the host, leading to replication and the formation and release of new phage particles, destroying the host bacteria in the process. The use of phages to treat bacterial infection – phage therapy – has a long history. Phages were first used to treat bacterial infection in 1919, heralding a ‘golden era’ for phage therapy in the 1920s and 30s. But a lack of understanding about what phages were and the mass production of antibiotics saw the demise of phage therapy from Western medicine2. Today, the antimicrobial resistance crisis is driving a renaissance in phage therapy. Aside from the ability to kill antibiotic resistant bacteria and a promising safety profile, from an orthopaedic perspective phage therapy is particularly attractive as some phages can degrade biofilms3. This might offer the opportunity to retain metalwork in complex, chronically infected arthroplasties. Clinical and safety trials have consistently demonstrated the safety of phage therapy by a variety of routes5. This is perhaps unsurprising given our coevolution and coexistence with phages. However, clinical trials have yet to consistently demonstrate the efficacy of phage therapy, although this is largely considered to reflect shortcomings in previous trials. Reassuringly, where sufficient phage(s)

have been delivered to susceptible bacterial cells, efficacy has been observed4. Moreover, there is a substantial and compelling body of observational data supporting the efficacy of phage therapy among patients with difficult-totreat infections. A recent systematic review of observational clinical data from patients treated with phage therapy since the year 2000 found that 79% of 1,904 phage-treated patients saw clinical improvement and 87% of 1,461 patients achieved bacterial eradication5. Similarly, two systematic reviews of phage therapy for orthopaedic infections reported efficacy rates of 71-93%, when used in addition to antibiotic therapy and surgical procedures6,7. Currently there are no licensed phage therapy medicinal products. Phage therapy is therefore used in the UK and elsewhere on an unlicensed basis, when licensed medicines have not fulfilled clinical need. Nonetheless, in recent years the American Antibiotic Resistance Leadership Group and Health Improvement Scotland have recommended phage therapy be considered for difficult-to-treat bacterial infections8,9. Phage therapy has been used in cases of difficultto-treat orthopaedic infections in multiple countries, including Israel, Belgium, France and the United States mainly in addition to standard therapy – surgical intervention plus prolonged antibiotic therapy10–13. Here we present the first use of phage therapy to treat an orthopaedic infection in the UK.

Case The case is an 84-year-old patient with a left total hip arthroplasty done in 2019 for a neck of femur fracture. The patient presented three years later with a peri-prosthetic infection after haematogenous spread from an infected skin biopsy site. The patient was concurrently diagnosed with chronic lymphocytic leukaemia (CLL). The patient also had a history of penicillin and teicoplanin allergy. A methicillin-sensitive Staphylococcus aureus (MSSA) was isolated

Features

John Dunn is a specialist clinical pharmacist in surgery, orthopaedics and critical care in NHS Tayside with a special interest in bone and joint infections. He holds an MSc in advanced clinical pharmacy and is a pharmacist independent prescriber.

initially from blood culture and subsequently from intraoperative samples. During a total period of 12 months the patient underwent two-stage revision, followed by excision arthroplasty and further surgical debridement, alongside prolonged antibiotic therapy according to sensitivity patterns and the patient’s antibiotic allergies. Despite repeated surgical interventions and active and suppressive antibiotic treatments, the patient continued to have a sinus and raised inflammatory markers. In May 2023, the patient was readmitted with fever and a CT scan of the hip showed recurrent collections within the left hip and ipsilateral sartorius muscle. The patient gave

informed consent to undergo further surgical debridement with intra-operative and postoperative administration of anti-staphylococcal phage therapy. The susceptibility of the MSSA isolate to phage therapy was determined as reported elsewhere14. Two cavities – the hip joint/pelvis (via a defect in the quadrilateral plate) and the anterior thigh – were debrided and washed out with a phage solution, after application in the first instance of a sodium bicarbonate 1.26% solution. A short-lived and self-resolving diffuse, non-irritable erythema around the surgical wounds was noted after the administration of phages.

Graeme Nicol was the lead clinician in this case. He is an Orthopaedic Consultant with specialist interests and training in hip and knee replacement surgery, as well as hip joint preservation surgery. Figure 1: Preoperative clinical photograph showing obvious sinus in the patient’s wound.

Dr Daniela Munteanu is an ID consultant and Bacteriology Lead in the Department of Medical Microbiology in NHS Tayside, Dundee. She has 13 years of clinical and research experience in the field, with a special interest in bone and joint infections. Figure 2: Post debridement demonstrating healthy tissues and large soft tissue defect.

During the procedure, drains were placed into the two cavities to facilitate further administration of phages postoperatively. Intra-operative cultures yielded MSSA and Pseudomonas aeruginosa. The patient was started on intravenous (IV) daptomycin before surgical debridement and IV ciprofloxacin was added postoperatively when culture results became available. Phage therapy was administered via the two drains three times a day, for a total of four days postsurgery followed by removal of the drains. Immediately after the procedure the patient was intermittently febrile (up to 39oC). A decision to discontinue the local phage administration was made and her fever settled with no more spikes in temperature when phage therapy was resumed. No increases in LFTs were observed during this time. Cultures from drain fluid and drain tips were positive only for Pseudomonas aeruginosa and no MSSA was isolated after phage administration. Two weeks after initial surgery, the patient had a further washout and debridement for a non-healing wound and rising inflammatory markers. Deep samples from this procedure again grew Pseudomonas aeruginosa and no MSSA was observed. Samples were also tested by 16S PCR for MSSA and they were negative. The antibiotic regimen was changed to IV ciprofloxacin and meropenem, followed by administration of meropenem alone due to changes in sensitivity pattern for Pseudomonas. The total duration of antibiotic therapy was six weeks after the last surgery. >>

Features

There is understandably growing excitement around the potential impact of phage therapy, however the field remains at an early stage and it is important to manage both patient and clinician expectations15. Phage therapy is likely to be particularly advantageous in cases where metalwork cannot be removed. Although phage therapy may be considered by existing local MDTs in unique cases where alternative treatment options have failed, more robust clinical trial data will be needed before more routine use. Trials of phage therapy for orthopaedic infection are ongoing and we await the results with much anticipation16.

Bacteriophage Q&A

Figure 3: Post-operative photograph showing wounds closed with insertion of surgical drains to be used for administration of phage therapy on ward post-op.

A whole-body FDG-PET was performed six weeks after antibiotics were stopped and the result was consistent with ongoing inflammation, rather than infection. At six months follow-up, the patient’s wound remains healed, the C-reactive protein (CRP) normal and patient is able to independently ambulate.

Discussion points This case illustrates the exciting potential of phage therapy in a patient whose infection had previously been refractory to surgical interventions and antibiotics. However, as a combination of debridement, antibiotics and phage therapy were used simultaneously, it is not possible – despite compelling phage sensitivity data from the lab – to conclude that phage therapy alone was responsible for resolution. Phage therapy has an extremely promising safety profile. However, adverse effects have been observed – as in this case – although these are not generally considered to be caused by the phages themselves. Debris released from bacteria killed by phages has the potential to cause adverse effects. It has been suggested that this may underlie several reports of transaminitis among orthopaedic patients treated with intravenous and/or intraarticular phage therapy11. Transaminitis has not been consistently reported among orthopaedic phage cases and was absent from our patient. Manufacturing contaminants, such as immunostimulatory endotoxin (lipopolysaccharide), can also create adverse effects. Local redness at the site of phage administration, as observed here, has been previously observed and attributed to contaminating endotoxin10.

How can phage therapy be administered? Phages are typically provided as a suspension that can be administered in a wide variety of ways. For example, phages have been administrated topically (in infected diabetic foot ulcers), orally, intravenously, rectally and as in the current case, directly into wound cavities5. In future, we can expect to see phagecoated dressings, gels, catheters and other implants. Current evidence suggests that local administration is preferable to intravenous, with some phages rapidly cleared from blood17. What are the risks of phage therapy? Current evidence suggests that the phages themselves are safe4,5. However, debris from bacteria killed by phages or manufacturing contaminants can cause mild adverse effects10,11. As phages are not human pathogens, they have been successfully used in immunocompromised patients18.

Figure 4: After debridement, phage therapy can be administered directly into the wound cavity, left for several minutes, and then washed out. Further doses can be administered into the wound via a surgical drain in the post-operative period.

Can phages treat bacterial biofilm? Some phages have polysaccharide depolymerases, which can degrade biofilms. Phages can also enter dormant bacterial cells and become active when the bacterial cell ‘wakes up’3. Are there any reports of allergy to phages? We are unaware of any published reports of allergy to phage therapy and phages are considered suitable for those with antibiotic hypersensitivity. Who should be considered for bacteriophage therapy? Patients with infections which may be resistant to multiple antibiotics, susceptible but not controlled by antibiotic therapy (as in the case presented), who have contraindications to or intolerable side effects from antibiotic therapy or those deemed an unacceptably high-risk surgical candidate8. These decisions should be made by existing local multi-disciplinary teams.

Acknowledgements We are grateful for the support of the wider NHS Tayside Pharmacy in delivering the phages for this patient, especially the support provided by Kirsteen Hill (Antimicrobial Pharmacist). We are also grateful for the support we received from the Queen Astrid Military Hospital, Brussels, and the Eliava Institute, Tbilisi. n

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

Figure 5: Orthopaedic surgeon during administration of phage therapy.

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Features

The history of surgery in the treatment of traumatic brachial plexus injuries Tom J H Quick

ust like the brachial plexus itself, the history and global development of surgery for traumatic brachial plexus injuries (TBPI) brings together many strands and only reaches acceptable functional utility when all these threads are interwoven.

Tom Quick is a peripheral nerve surgeon and clinical academic recognised internationally for his expertise. He is an Honorary Associate Professor in the Institute of Orthopaedics & Musculoskeletal Science and a founding member and clinical lead for peripheral nerve in the Centre for nerve engineering at UCL. He collaborates scientifically with a wide range of academic teams in London and has published over 50 peerreviewed papers. He has produced national guidelines in nerve injury and is an ABC travelling fellow.

This story is often linked with many names of individuals who have contributed to this field, and it is to Rolfe Birch that I dedicate this overview of the history of the field in which he was a master. As a student of Bonney, and thus in the lineage of Sir Hebert Seddon and George Bonney, Birch was to popularise the method of an intellectual approach, meticulous focused enquiry, collegiate working and precise surgical skill for which his practice was famous. For all of us, he was an individual who not only taught the approach but also referenced the history of this particular niche area of medicine and surgery. The state of art now, in the world that Rolfe Birch has left, holds so many of the basic principles of his work: • Respect for the patient and their needs. • Teamwork across specialities. • The importance of rehabilitation. • The necessity as a clinician to hold oneself to ‘truth’ and personal responsibility (especially when the data is unreliable). In celebration of Rolfe, I end this article by looking to the future of brachial plexus injury treatment. What is likely to be possible in a world where we build upon this history of development and work to improve outcomes for those with such injuries. “There must be a beginning of any good matter, but the continuing to the end, until it be thoroughly finished yields the true glory”. Drake to Walsingham (Chapter 9 ‘The Closed Supraclavicular Lesion’ in Surgical Disorders of the Peripheral Nerves, 2nd Edition, Rolfe Birch).

In the beginning It would be ideal to have a complete history of this area of work to span from ancient times to the modern day. However, in the beginning, the early physicians did not differentiate the nerves from tendons or ligaments. They were all grouped as ‘the sinews’ (neuros in Latin). In the Nordic Saga, it was these sinews that were used to bind Fenir (the giant wolf that killed Odin) but the restraints were too loose to be useful. So was the concept of ‘sinews’ in advancing the appreciation of nerve injury treatment. The writings of Hippocrates recognise that these sinews could not be repaired with any success (unlike bone or muscle, which was seen to heal well). One could only hope that the enlightened ancient physicians held the secret of nerve repair but there is only one record of a nerve repair by suture (using human hair) of a lacerated sensory nerve at the ankle by Hippocrates1. Galen realised the difficulty of exposing and studying the brachial plexus: “Now all the nerves going to the hand have been so cleverly concealed that even most physicians are unfamiliar with them.” A view that is not that rare even today! Galen did however describe the anatomy of the Cervical and Brachial plexuses in the 13th century book ‘De Usu Partium Corporis’. From this point on, the history oscillates between enthusiasm and indifference. “The pendulum swinging back and forth between treatment and no treatment for centuries” (Walter 2015). Authors in Taiwan2 have written an excellent history of the international development of brachial plexus surgery where they describe four ages of development:

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Rolfe Birch

The period of Recognition, Pessimism, Improvement and Advancement* (which I have renamed from ‘Improvement II’ in their original text). To this history I believe that we are about to enter a period of ‘Biologic Augmentation’. We will, through the use of therapeutic medicines, electrical stimulation and tissue production be able to not only manipulate the anatomy of injury but to augment the biology and physiology of regeneration resulting in better functional recovery.

Period of recognition (pre 1900) From the ancients to the late nineteenth century there were a few successful treatments for traumatic brachial plexus injuries (TBPI) beyond infrequent case reports. Silas Wier Mitchell, a surgeon in the American civil war, is a notable personality in the history of TBPI. He worked in the Turner’s Lane Hospital (the first hospital devoted to nerve injuries) to understand musket ball injuries to the nerves (Injuries of Nerves and Their Consequences, 1872). Mitchell is well recognised for what he termed ‘causalgia’ and he also wrote about assessment using 1 and 2 point tests and the value of testing temperature. He

wrote about the potential value of experimental peripheral nerve surgery and recorded muscle strength by manual evaluation. He described differing degrees of nerve injury, described ‘Saturday Night’ and ‘Crutch’ palsy and first described conditions which were later to be named as the Hoffman-Tinel and Horner’s Sign. Many, like Mitchell, seem to have been prescient of the future whilst their work did not find wide acceptance in their own time. Adolf Stoffel who spans this period into the first period of Pessimism described many of the advances particularly of nerve transfer techniques that only became popular a century later.

Period of pessimism (pre 1964) Many surgeons worked tirelessly diagnosing, assessing and treating brachial plexus injuries to only find unsatisfactory results from their surgery. Kennedy (1903), Sever (1925), Barnes (1949), Boney (1959). In retrospect, this pessimism was due to a lack of understanding of the impact of tension on nerve repair and on the time necessary to see functional recovery.

deaths and poor results, surgery for such injuries were abandoned in the 1920s. The history of brachial plexus surgery within the UK grew out of World War II. Soon after the end of World War II, centres were established to support treatment and rehabilitation of soldiers with limb injuries. The knowledge of polio’s effect on the limbs had led to development of methods of tendon transfer to treat upper limb paralysis. Primary nerve repair took a back seat and reconstructive surgery was the main method of treatment. After the war, the number of injuries fell. Supraclavicular injuries of the brachial plexus occur due to high energy closed or penetrating trauma. During peacetime it was the closed injury (severe forced traction between head and shoulder) which resulted in devastating injuries. Prior to modern road safety, the mechanism which created such injuries often lead to death of the individual negating any need of intervention on the nerve injury. Rehabilitation was the major focus during this time and the work of Kit Wynn Parry led in this field. Similarly, following World War I, the initial enthusiasm for primary nerve surgery fell in the 1940s. However, the contributions of those brought together by the British Medical Research Council laid the foundation of what was to come. Brooks (1955) established the role of nerve grafting; Seddon (1963) described the first case of active elbow flexion after intercostal transfer and Young and Medawar (1940) introduced fibrin-clot glue. In the UK, it was Sir Herbert Seddon who led the field. He was the Nuffield Professor in Oxford in the 1940s. He specialised in polio treatment and tuberculosis of the spine and moved to the Royal National Orthopaedic Hospital in London in 1949. In 1965 he become the first Professor of Orthopaedics in the newly formed Institute of Orthopaedics. He believed in the benefits of nerve and brachial plexus surgery and ushered in the age of Improvement.

“One could only hope that the enlightened ancient physicians held the secret of nerve repair but there is only one record of a nerve repair by suture (using human hair) of a lacerated sensory nerve at the ankle by Hippocrates.”

The intermittent advances within this period were often generated during military conflict. Prior to the industrial revolution and motor travel, ballistic trauma was the most frequent mechanism for such injuries to the brachial plexus. There were very few surgeons undertaking this type of surgery during World War I and due to many

In 1954 a Special Report of the Medical Research Council commenting on 170 open war-time injuries concluded that: “with the possible exception of lesions of the upper trunk, operative repair is valueless”. This view was supported at the Paris SICOT meeting in the mid-1960s. Nerve injury experimentation on animals >>

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and humans grew and there was more appreciation of the biology of regeneration of nerve fibres. It is at this point that the threads of successful TBPI surgery started to come together. Advances in road safety, acute medical care, microscopic equipment and the experience from the rehabilitation of military casualties fed into the birth of successful brachial plexus surgery.

Period of improvement (1964-1999) The commencement of this period in the UK was marked by the address of Sir Herbert Seddon at the Royal College of Surgeons where he delivered the Fourth Watson-Jones Lecture entitled ‘Nerve Grafting’. “When the Second War started we had to ask ourselves whether the unsatisfactory results had been due to what might be called biological futility or, on the other hand, whether nerve grafting was theoretically sound but had failed because of imperfections of technique.” He cited the work of his colleagues Young, Medawar, Sanders and Holmes in describing the improvement in outcomes once recognition of the impact of tension on primary nerve repair and the possibilities of autograft had been appreciated. Seddon led the diagnosis and assessment of nerve injuries through his Medical Research Council (MRC) publications and popularised a classification of nerve injury. His book The Surgical Disorders of the Peripheral Nerves published in 1971 became a seminal work in the field. Further editions were published in 1998, 2011 and 2016 under the editorship of Rolfe Birch and his mentors George Bonney and Kit Wynn Parry. In the book, Birch describes his experience in 1962 at St Mary’s Hospital where poor clinical outcomes led to a cessation of brachial plexus surgery after 41 cases. The restarting of brachial plexus surgery in 1975 (four years before Rolfe was to join this unit) was stimulated by the work of Algiamantas Narakas.

The right brachial plexus with its short branches, viewed from in front. The Sternomastoid and Trapezius muscles have been completely removed, the Omohyoid and Subclavius have been partially removed; a piece has been sawed out of the clavicle; the Pectoralis muscles have been incised and reflected. From Henry Gray (1918) Anatomy of the Human Body.

Success after 1964 was driven by the development of microsurgery. The first use of a monocular microscope was in 1921 in Sweden for inner ear surgery and in California in 1957 a binocular microscope was first used in neurosurgery.

“We will, through the use of therapeutic medicines, electrical stimulation and tissue production be able to not only manipulate the anatomy of injury but to augment the biology and physiology of regeneration resulting in better functional recovery.”

International interest was rekindled by the work of Narakas in Switzerland and Millesi in Vienna in the early 1960s. With nerve grafting, the principles of complete resection of damaged tissue, graft selection/preparation and tension free deployment the technique became universally adopted.

Period of advancement (1964-1999) The advancement of basic science in the 1990s strongly supported the approach of early intervention following nerve injury to maximise outcome. The maxim ‘time is muscle’ defines our core principle in treating TBPI.

The seemingly unimprovable growth rate of axons in native (even slower in auto or allografted) tissue together with the recalcitrance to reinnervation caused frustration for surgeons. In a supraclavicular brachial plexus injury, which is graftable, there is a limit to how far the nerves can grow before the return of muscle function is lost.

There was (and still is) no advance in the ability for invention to prolong muscle receptibility to reinnervation but the solution came from a technique which had been used throughout the past 100 years. That was nerve transfer. Instead of taking nerve from other parts of the body as free tissue where the axons are no longer attached to the brain and will degenerate leaving a biologic scaffold, nerve transfer uses sacrificable nerves close to the denervated muscle. It redirects growth too quickly reinervate the paralysed muscle. This technique led to an improvement in the degree of possible recovery. Narakas (1988), Oberlin (1994), Levenchevnchongs (1988), Mackinnon (2005). The development of spinal nerve reimplantation following avulsion injury by Thomas Carlstedt in the 2000s provided another technique to increase the range of conditions for which there was a surgical option. In parallel with the advances in the art of surgery, the science of nerve injury improved our understanding of the cellular and molecular events that occur after a nerve is injured. This evidence base has informed the timing of treatment and the urgent, time dependent nature of these injuries. For a review of the history of nerve injury science I recommend Susan Standring 2020 review3. >>

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all aspects of society. Traumatic brachial plexus injuries are complex and multifaceted. The care afforded them should be similarly multifaceted. Assessment of the injury should recognise the need for both biologic and functional assessments4 and the correct selection of both patient and clinician assessed outcome measures is also important5. There are hopes that a biomarker6 will be shown to have clinical utility in assessing the amount of axonal injury to support diagnostic classification and inform prognosis. Further, we hope that in the future drug therapies (Gong 2023) and other modalities (Ni 2023) may be able to improve the outcomes in all degrees of nerve injury independent of surgical intervention.

Model of brachial plexus gifted to the RNOH PIN unit.

Despite many decades of research, it is a sobering thought that functional outcomes after repair still remain unsatisfactory. We still struggle to identify the degree of injury and predict with any certainty the degree of recovery likely with natural recovery. We still struggle to precisely define each injury, to measure recovery and grade what is good (across all the complex modalities of movement and the nuance of touch). We have no biomarker of injury and no imaging techniques which shows the injured physiology except for gross anatomy. As yet, we have no therapeutic drug to improve outcomes. Furthermore, supporting and encouraging patient engagement and the psychological health of the patient is a key to good outcome. These are the challenges in the field.

Period of biologic augmentation (2023 onwards) The fundamental principle in brachial plexus surgery is to establish an accurate diagnosis and then to attempt to improve the prognosis. Prompt surgery has been shown to be a central part of this.

“When the Second War started we had to ask ourselves whether the unsatisfactory results had been due to what might be called biological futility or, on the other hand, whether nerve grafting was theoretically sound but had failed because of imperfections of technique.”

Brachial plexus surgery is now known to be safe and we have many surgical tools and techniques to deploy and much collected experience to assist decisionmaking. In order to understand its natural history we must collect more specific data on injury and its rehabilitation. It is insufficient to revel in anatomic repair if the patient fails to maximise their reintegration into

Reflecting upon the personalities who have shaped the past of nerve injury and in recognition of their contribution to the future, brachial plexus surgery will continue to follow the basic principles of treatment. The assessment of the degree of injury, its anatomic location, multimodal treatment and a focus on education of the patient towards rehabilitation. “The important advances of the last 30 years include: refinement of diagnosis; relearning and re-application of the principles of the treatment of wounds and vascular lesions; improved methods of nerve repair and transfer; and, most importantly, a policy of urgent exploration and repair... together with new knowledge about the roles of neurotrophins in preserving cell bodies within the spinal cord and enhancing regeneration, there is now a real prospect of mitigating the worst of all injuries to peripheral nerves.” Birch R. Brachial Plexus Injuries. J Bone Joint Surg Br. 1996;78(6):986-92. n

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

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Chetan Khatri is a PhD student at Warwick Clinical Trials Unit and a ST3 trainee in the Warwick Orthopaedic Specialist Training Programme.

urgery is a multi-faceted complex intervention with procedures having a variable influence on different domains of recovery (such as pain, function, long-term outcome etc.). When compared to new drugs, evaluation in surgery provides unique challenges when assessing how effective treatments are, as well as safety or health economic concerns. In the previous article, we described the current challenges of device regulation and evaluation in Trauma and Orthopaedics. In this second article of this two-part series, we describe how surgeons can use data wisely and contribute to initiatives led by the orthopaedic community.

Registries and routinely collected data

Steve Gwilym is a Consultant Orthopaedic Surgeon specialising in the management of shoulder disorders and his research interests are focused around optimising outcomes after traumatic injury and upper limb surgery. Professor Gwilym chairs the British Elbow and Shoulder Society Research Committee.

Data from case series are widely used in new innovations, but one of the limitations of this approach is that they typically performed by single surgeons or units, reporting independently of each other. This is an improvement on not reporting at all, but important lessons may not be learned across units that could be picked up earlier by collecting data collaboratively. For this, registries can be much more powerful, although they need to be set up, funded, and resourced in such a way that data completeness is high, and data can be analysed and reported efficiently. In addition to this, coordinated efforts between clinicians across sites that are introducing new procedures, potentially using trainee collaborative models, can make a major difference to ensuring safe practice.

One of the great successes of coordinated data collection has been the National Joint Registry (NJR), which may, at least in part, explain the steady improvement in revision rate for major joint arthroplasty across the UK since the NJR was launched1. Oversight of the data includes an implant scrutiny committee, comprising a multidisciplinary group including surgeons, NJR representatives, Medicines and Healthcare products Regulatory Agency (MHRA) and Orthopaedic Data Evaluation Panel (ODEP). Through periodic (six-monthly) analysis the group can identify implants that are performing suboptimally. More recently, the issue of ‘implant camouflage’ has been identified, with families of implants under the same brand masking poor performance in certain specific combinations of implants2. Closer scrutiny may be required, and surgeons need to be aware of the performance of their specific chosen combination of implants rather than relying on a trusted brand. The Beyond Compliance initiative is an excellent example of good practice in innovation. Beyond Compliance is an independent organisation with stakeholders from multiple specialist societies designed to evaluate and monitor the early performance of new or modified implants for most total joint surgery (e.g. knee, hip, shoulder). Under this framework, potential sequalae related to a product can be identified before widespread use. The same principles are not applied to nonarthroplasty devices in orthopaedics at present, where oversight of new products may be very limited. Multiple orthopaedic registries have been

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established, under the umbrella of the Trauma & Orthopaedic Registries Unifying Structure (TORUS), such as the National Ligament Registry and the UK National Hand Registry amongst many others, to routinely collect outcomes from patients. However, these have had variable uptake from surgeons and follow-up rates have often been suboptimal.

Keith Tucker was involved in the introduction and development of the NJR. He is chair of ODEP and the Beyond Compliance advisory group and a member of NORE. He is a member of the MHRA metal on metal group. He is a retired orthopaedic surgeon.

Edward Davis is a Consultant Orthopaedic Surgeon in Stourbridge and the West Midlands.

A similar framework to Beyond Compliance, with a wider application across orthopaedic subspecialties and devices could provide a unified approach from the community to innovate and evaluate new interventions. NHS England, under direction of the Department of Health and Social Care and in response to the Cumberlege report, has recently launched the Outcomes and Registries Programme, which will capture data on all implanted medical devices; an initiative that is supported by the British Orthopaedic Association and Royal College of Surgeons of England3. This has the potential to reduce the time needed to conduct device recalls and issue safety alerts. Patient-reported outcome data will be routinely collected and analysed for specific surgical procedures, supported by clinical leads for existing and emerging registries, and this presents an ideal opportunity to routinely embed rigorous device evaluation alongside orthopaedic innovation. For new procedures, an anonymised, centralised reporting system for adverse events after an intervention may also help improve product safety. Within aviation and maritime industries, the confidential human factors incident reporting programme (CHIRP) provides such infrastructure4. The CHIRP platform allows reporting of issues related human skills, performance and training, new instrumentation, and organisational structures. Even small issues, which may represent a minor frustration to the individual, but across a large number of events may be important, can be identified and rectified with such this system. An adaption of this may provide a multifactorial reporting tool. With effective systems we can innovate safely with the requirement of minimal administration burden for surgeons and produce robust safety data. This is a challenge for all surgeons to meet, but with

strong infrastructure we could provide a method for safe innovation that avoids many of the problems inherent in our current systems.

IDEAL framework and the role of trials In 2009, a large group of surgeons across multiple specialities published a framework for the introduction of new surgical procedures, called the IDEAL framework5. Their recommendations are straightforward and logical, but are still only infrequently used, or applied in a patchy manner. The initial stages (1-2b) are based on development and exploration of an innovation. These use case series and cohort studies to focus on safety, refining the technique and indications and establishing the learning curve. At this stage all cases performed should be analysed and results reported. They may provide early indications of a possible signal of benefit, but they are unable to provide a definitive result. The latter stages (Stages 3 and 4), focus on RCTs to establish efficacy and once proven, stage 4 focuses on long term monitoring through registries6. In the past, there was a paucity of randomised trials in orthopaedics, with the editor of the Lancet asking whether it was ‘surgical research, or comic opera’7 in 1996. Surgical trials can be much more complex to deliver than in other medical specialities. Interventions are often complicated, requiring coordination between radiology, surgical pathways, and rehabilitation. Appropriate outcome measures, often PROMs, are challenging to collect without excessive loss to follow-up. For certain outcomes, such a revision risks in arthroplasty, the numbers required for trials may be restrictive, with a methodological paper estimating an excess of 3,200 procedures would be required to measure differences using traditional trial methods, although some studies have managed to deliver at that sort of scale8,9. Orthopaedic trials have become much more frequent in recent years and with this growing experience, the UK is establishing a growing body of expertise, an effective national network, and a worldwide reputation for delivering trials. >>

Professor Xavier Griffin is the Chair of Barts Bone and Joint Health, and leads academic orthopaedics at Queen Mary University of London and Barts Health NHS Trust. Xavier’s vision is for world-class excellence in research and clinical academic training; providing opportunity for the next generation of clinician scientists to realise their aspirations.

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Whilst clinicians may not have dedicated academic time to lead multi-centre trials, they can always recruit or lead them locally and make a major contribution to the delivery of the high-quality evidence that is needed. The introduction of the Associate Principal Investigator scheme from NIHR has led to early exposure and clinical research training for orthopaedic trainees, building a culture that trials are part of our clinical practice.

David Beard is Professor of Musculoskeletal and Surgical Science and Director of the RCS England Surgical Trials Unit at Oxford University (SITU NDORMS). He has a long-standing interest and expertise in trials for the evaluation of devices and surgical innovation, particularly for surgery and complex healthcare interventions.

Andrew Metcalfe is Professor of Orthopaedics at the Warwick Clinical Trials Unit, and a Consultant Orthopaedic Surgeon at University Hospitals Coventry and Warwickshire where he specialises in knee surgery.

A careful consideration is the timing of a trial for a new intervention. If done too early or in a poorly considered way, the costs and administrative burden risks stifling innovation. Early trials may also capture technologies too early into their development cycle; the early development of a technology often involves the culmination of iterative changes resulting in a device or technology that has a far more meaningful effect. If trials are done too late, equipoise may no longer be in place amongst the wider community and in particular early adopters. There is a risk of thinking “it’s always too early, until it’s too late”. Although with information and education, the importance of proving the effectiveness of interventions in trials is becoming increasingly widely accepted. We are starting to see trials earlier in the adoption of new technology, although this is far from universal. For example, robotic arthroplasty has been tested in small trials and now two large trials recruiting in the UK, which will provide high quality evidence for surgeons relatively early in the innovation cycle10-13. This is on the background of a major growth in robotic arthroplasty around the world, suggesting that although trials are being embedded earlier in the process, they are not yet being completed ahead of widespread adoption. An example of effective innovation using randomised trials is lateral tenodesis with ACL reconstruction. The STABILITY trial was an international randomised trial in which surgeons performed ACL reconstruction with or without tenodesis for people at high risk of ACL rerupture14. It found lower rates of graft failure or ongoing pivot-shift, with no disadvantage in PROMs, when a tenodesis was used. This has changed ACL practice for many surgeons internationally, who do so in the confidence of having RCT evidence to support their practice. Clinicians and researchers alike should embrace placebo-controlled trials in surgery where appropriate and possible15. The precedent set by placebo-controlled trials in arthroscopy, such as CSAW, have demonstrated them to be viable in surgical settings16. The use of shams or placebos may be particularly valuable in testing new innovations or devices where the mechanism of effect is questionable, and the placebo effect of surgery is potentially high. It allows testing of the innovation by isolating it from non-specific effects. The journey from the decision to undergo a surgical procedure to recovery involves components (such as type of anaesthetic used, analgesic provided) that may individually, or cumulatively have a greater effect than the surgery itself.

There is now a large network of Clinical Trials Units (CTU) across the UK and an established group of centres with experience of orthopaedic trials co-ordinated by the British Orthopaedic Association. Trials units are often interested in new ideas and study topics and as NIHR structure evolves over the coming year, merging CTUs with Research Design Services, they will increasingly be able to support clinicians and new investigators to design and deliver high-quality and large-scale research studies. In particular, the Exeter and Nottingham Clinical Trials Units have a specific remit to support investigator-initiated projects from British Orthopaedic Association members. Trials are, however, still typically slow to set-up and deliver, and there is a major body of work to be done by healthcare leaders and researchers to develop and deliver trials faster. Efficient or platform trials, exemplified by the WHiTE platform, has provided a framework designed to efficiently deliver multiple, iterative interventions for people with hip fractures and has transformed the evidence base17. START:REACTS as an example of an efficient design18, or adaptive platforms such as ROSSINI2 trials in other surgical fields19, may help us to deliver the efficiency and scale needed to deliver the volume of trials that is increasingly needed by clinicians and patients. Other designs focus on system changes, such as the REINFORCE study, which will measure the impact and assess implementation of a new intervention (robotic assisted surgery, across several specialities) as it is introduced and scaled up across the UK20.

Summary Innovation can bring great benefits for patients, but with technology developing rapidly and often outpacing its evidence base, we need to be increasingly wise about how we innovate as surgeons. Data is now a mandatory part of innovation and is best done in a coordinated way across units. Systems to improve the way we capture data should ideally be easy to implement at sites and straightforward to deliver for busy clinicians but produce meaningful results across units. We can no longer rely on case series data to prove that treatments are effective and whilst trials have been valuable in identifying both beneficial and detrimental treatments in a number of areas in trauma and orthopaedic surgery, trials are also limited by their cost and lead time. A commitment to testing effectiveness and safety should be a prerequisite to introducing any innovation. Working together, as a collaborative group, we can protect patients and deliver the data needed to innovate effectively and safely. Safe innovation will also provide industry the data it needs to support effective new technologies, benefitting us all. Increasingly as surgeons we should demand data on implants and technologies we use. If we can deliver this as a community in the future, we will find ourselves continuing to improve care for patients with confidence. n

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

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Features

Factors affecting the supply of medical devices to the NHS Richard Devereaux-Phillips

he design, manufacture and distribution of medical devices is a complex, typically international process. There are four elements that need to be considered by any jurisdiction wanting to ensure supply chain continuity. Availability of ingredients / raw materials, the ability of goods to move frictionlessly across borders, arrangements for product regulation, and the commercial environment for suppliers.

Richard Devereaux-Phillips is Director of Strategy for the Association of British HealthTech Industries (ABHI). He joined the ABHI in June 2015 with over 20 years’ experience in the pharmaceutical and medical devices industries. Richard holds numerous advisory roles in the HealthTech space and in January will complete a seven year tenure as a Non-Executive Director at the Royal Orthopaedic Hospital in Birmingham. He served from 2003 until 2013 as a member of the Technology Appraisal Advisory Committee of the National Institute for Health and Care Excellence and is a former Chair of the South West Academic Health Sciences network and the Programme Board of the Small Business Research Initiative Healthcare.

Established manufacturers have become adept at predicting and mitigating against raw material shortages, but serious shocks can still occur. A recent example was the shortage of microprocessors, a market where supply famously fluctuates and has traditionally seen Taiwan produce a disproportionate amount of the world’s supply. For medical devices, the situation was exacerbated by the fact that the industry represented only about 2% of the global market, so when it came to the pinch, suppliers looked first to satisfy their largest customers, mainly the automotive sector. Device manufacturers were left to appeal to the better nature of their suppliers to ensure that medical technology production could be maintained1,2. The war in Ukraine has changed some raw material supply lines and changed the prioritisation of material supply. The standard response from governments is to talk about onshoring or reshoring manufacturing, but, as we found out during the pandemic, it comes at a cost. It is possible to make high quality PPE in the UK, but not at a price that the NHS is prepared to pay. The UK has suffered peculiar problems in the movement of goods since leaving the European Union. Larger manufacturers supplying the UK tend to move their products, wherever they are manufactured, to distribution centres in the Low Countries for onward delivery. For example, needles and tubes for blood sample collection are manufactured in very high volumes in Plymouth and are then moved by road to Belgium from

where they are reimported back into the UK. Customs challenges post-Brexit, including a pre-approval process for products coming into the UK, that is only available through certain routes, mainly air freight, can cause delays in bringing in goods through other channels and also adds cost. A less visible, but equally if not more important factor, is how products are regulated, and that is presenting a serious challenge across Europe. The process for placing medical devices on the EU market is undergoing a major overhaul, and evidence requirements will be far more stringent. The changes, to a so called EU Medical Device Regulation (MDR &IVDR), were made in the name of patient safety but have had serious unintended consequences. Major reform in regulatory arrangements in any sector almost always involve raising the bar, and typically around 20% of products disappear from the market as a result. This is a particular problem for low volume and niche products. A company may be providing a decades old product with an established safety profile returning a revenue of several hundred thousand pounds, but the cost of recertifying the product under the new MDR could be in excess of £1 million. That is not a difficult commercial decision to make, but the situation for devices is further complicated. In the case of this reform a very large number of Notified Bodies, the organisations that certify conformity with appropriate regulations, decided to exit the medical device sector because of the additional burden. This has created a situation where even when companies have the appetite to do so, a lack of capacity amongst regulators has made it almost impossible to fully maintain existing portfolios. Alongside any removal of products, it is also likely that many will not be recertified for a full range of current indications. Using an implant in the same group of patients that it has been used in for many years, may now be regarded as off label.

Features

The consequences for European patients are real and very significant. Last year a survey by the trade body MedTech Europe on regulation and the impact of MDR stated that 45% of companies are deprioritising the EU as a market for first regulatory approval3. The winner is, almost certainly, the US where the Food and Drug Administration (FDA) has a predictable, timely, and well-resourced process. One of the freedoms afforded by Brexit is, of course, the fact that we no longer need to align ourselves with EU arrangements. The UK regulator is currently making very positive noises about using a reliance model to allow products approved in other trusted jurisdictions smooth access to the UK, a “rapid, near automatic, approval” as HM Chancellor of the Exchequer described it in his March budget speech. We also need to take care, because any additional requirements to enter the UK market are exactly that, additional. There is a salutary lesson here from Switzerland, which recently lost its mutual recognition of conformity assessment with the EU. The Swiss put additional requirements in place for CE marked products to be used in the country, to which many suppliers responded by removing products from the market. Faced with the prospect of a loss of products, often basic ones, but nevertheless ones essential to the practice of modern medicine, the Swiss are now moving towards a system which will recognise FDA approvals. Currently the UK relies on CE marking as it moves towards its own sovereign regulation for medical devices, and will do up to 2030,

a situation that has been extended indefinitely in other sectors. Opportunities for innovative regulation for innovative products abound, something that could make the UK an attractive location not only for our own companies, but also those wishing to invest here. We must, however, proceed with caution. All of the above are drivers of intense inflationary pressures on suppliers, yet the NHS maintains a zero price inflation policy by default, and is adopting aggressive procurement policies aimed at reducing cost with no reference to value. It is not sustainable, and in a recent ABHI survey, over a quarter of respondents reported that they had removed products from the UK because the price the NHS was prepared to pay, alongside increased costs to serve, made it no longer viable to continue to supply4. There are things we can do to mitigate the risks. The challenges described have caused companies to sit on lower stock levels, so clear, accurate demand signalling will be important to manage stock levels and ensure products are in optimal locations. It should also be remembered that as we continue to recover and increase our elective volumes, surges in volumes need to be planned for. Lead times to increase production for instrumentation are a minimum of six months, and it is around 12 months for implantables.

We can be pragmatic about product regulation, allowing approvals of uncontroversial technologies from elsewhere, thus freeing up the regulator to focus on pro innovation regulation. The strong heritage we have in post market surveillance, championed by the orthopaedic sector, alongside the NHS’s data capacity has the potential to make our country an even greater powerhouse for research and development, while at the same time making it one of the safest for patients. We can also take a more enlightened approach to how we do procurement, considering value across patient pathways and not merely the acquisition cost of individual technologies. The Life Sciences Vision sets out an ambition to create an outstanding business environment for the sector. Together we can deliver it for the benefit of our country, our NHS, and the patients we serve. n

References 1. AdvaMed Press release. AdvaMed Submits Recommendations to Department of Commerce to Address Semiconductor Chip Shortage and Supply Chain Issues. Available at: www.advamed.org/ industry-updates/news/advamedsubmits-recommendations-to-departmentof-commerce-to-address-semiconductorchip-shortage-and-supply-chain-issues. 2. World Economic forum. Global chip shortages: Why supplies must be prioritized for healthcare capabilities. Available at: www.weforum. org/agenda/2022/05/globalchip-shortages-put-life-savingmedical-devices-at-risk. 3. MedTech Europe. MedTech Europe Survey Report analysing the availability of Medical Devices in 2022 in connection to the Medical Device Regulation (MDR) implementation. Available at: www.medtecheurope.org/ wp-content/uploads/2022/07/ medtech-europe-surveyreport-analysing-theavailability-of-medical-devicesin-2022-in-connection-to-themedical-device-regulationmdr-implementation.pdf. 4. ABHI / CPI HealthTech Business Confidence Survey (emerging data to be published December 2023).

Trainee

Kate Atkinson is an ST6 registrar on the Royal London Rotation. She is the BOTA Culture & Diversity Representative, BOA & BOTA Culture & Diversity Champion for London, and forms part of the BOTA Culture & Diversity Subgroup. She is also the founder of London Women of Orthopaedics.

• In 2020, we published our Diversity and Inclusion Strategy and Action Plan documents highlighting five priority areas. Good progress has been made over the last three years and an updated strategy and action plan is due next year. • In 2021, we developed our website resources covering pregnancy, parental and adoption leave, less than fulltime training and signposted our members to other complementary sites. • In 2021, we supported Pride Month with input from our members and from international colleagues • In 2022, we launched our inclusive orthopaedics initiative along with industry colleagues.

Zahra Jaffry is an orthopaedic registrar on the Percivall Pott Training Programme in London. She is also the Women in Surgery representative for BOTA and forms part of the BOTA Culture & Diversity Subgroup.

• In 2022, as a combined initiative with BOTA, we appointed a Culture and Diversity Champions programme and have joined BOTA in hosting two instructional days • In 2023, we ran an externally administered membership survey looking at Diversity, Equity, Belonging and Inclusion and via free text comments identified areas which require improvement.

t is widely acknowledged that a more diverse workforce, representative of its patients, can result in better outcomes1. Despite this, groups considered a minority, including based on race, sexual orientation, disability and gender, continue to face unique challenges during their careers. The importance of highlighting these and ways to overcome them cannot be overstated. These issues can also deter medical students and foundation doctors from considering a career in orthopaedics. Doctors from minority ethnic backgrounds are more likely to fare worse in both undergraduate and postgraduate exams and are twice as likely to be referred to the General Medical Council (GMC) than their white colleagues. International medical graduates (IMGs) are three times as likely to be referred to the GMC for fitness to practice concerns, compared to UK graduates2. Many speciality and specialist grade (SAS) doctors and locally employed doctors in surgery are from a minority ethnic background, and 32% reported bullying, undermining and harassment at work. IMGs are less likely to go into surgery at 21% compared to 28% of all licensed doctors3. The Royal College of Surgeons of England’s (RCSEng) Kennedy report on diversity and inclusion, published in 2021, called for attention to two particularly neglected areas, with there being “very little evidence of the experiences of LGBTQ+ surgeons” and “minimal evidence on the issues of surgery and disability, yet those with disabilities in the NHS report the highest levels of discrimination of any group”4. There is also increasing awareness of

Trainee

BHS Schools Engagement Group.

the need to further support colleagues who are neurodivergent, which includes conditions such as autistic spectrum disorder (ASD), attentiondeficit/hyperactivity disorder (ADHD), dyspraxia, dyslexia and Tourette syndrome, conditions which are becoming more frequently diagnosed in the population5. Many neurodivergent surgeons choose to hide their diagnosis and many LGBTQ+ surgeons choose not to be ‘out’ with their sexuality and gender identity at work, due to fear of stigma and discrimination6.

Karen Chui is an ST5 Registrar on the Stanmore Rotation and the current BOTA Vice President. Karen is part of the BOTA Culture & Diversity Subgroup and immediate past BOTA Culture & Diversity Representative.

Female surgeons have been shown to have fewer complications in studies that account for confounding factors such as case-mix7. However, growing research demonstrates that female surgeons are living and working in a different reality to their male colleagues. In a profession centred on care and the doctrine to ‘do no harm’, the health and safety of women working within it are constantly at risk. In the recent paper by the Working Party on Sexual Misconduct in Surgery (WPSMS), 63% of women surveyed had reported being sexually harassed and 30% sexually assaulted, compared to 24% and 7% of men respectively8,9. Female orthopaedic surgeons are two times more likely to have any type of cancer and three to four times more likely to have breast cancer than the rest of the population10. The risk of miscarriages and other pregnancy-related complications, such as preterm labour and low birth weight, are also higher in female surgeons, which may be due to aspects of their working conditions including long work hours, night shifts, prolonged standing and heavy lifting11.

Parenthood remains a factor with a significant impact on recruitment to the specialty. In a survey conducted by the Nuffield Trust, 36% of respondents stated they did not believe a career in surgery was compatible with being a parent. This also influences retention and progression, with 55% considering leaving due to parenting plans and work, showing that women returning from maternity leave moved through to senior roles more slowly or not at all12. There is a need for culture change to ensure that the profession gains and retains the best talent for its patients. Both the BOA and the British Orthopaedic Trainees Association (BOTA) have a long-standing commitment to increasing diversity in orthopaedics. BOTA Committee members have had the privilege to be at the forefront of this change, sitting on the WPSMS panel and contributing to the ground-breaking report on sexual misconduct in surgery. This work led to the launch of the NHSE Charter on Sexual Safety and has encouraged the GMC to update the Good Medical Practice guide8,9. Furthermore, BOTA Committee members have sat on the British Medical Association (BMA) Ending Sexism in Medicine pledge groups, reviewing policy and contributing to change and guidance13. The BOTA Women in Surgery (WinS) Representative is part of the BOA working group that released guidance on radiation protection and personal protective equipment, accounting for the need for axillary protection for female orthopaedic surgeons14. BOTA Committee members have also been a part >>

Trainee

Marieta Franklin is an ST8 registrar in Mersey. She is on the BOTA Committee as the Specialist Advisory Committee Representative and forms part of their Culture & Diversity subgroup. As a member of the British Hip Society Culture & Diversity Committee she leads their Schools Engagement Programme. Marieta is also a founding member of the Working Party on Sexual Misconduct in Surgery.

BOTA Female Committee Members at C&D Day.

Kriti Singhania is currently an ST7 registrar at Addenbrooke’s Cambridge University Hospital part of the East of England Deanery. She is the previous BOTA Vice President and was a founding member of the BOA and BOTA Culture and Diversity Programme. She is proud to see an idea she initially had come to fruition and continue to blossom thanks to the shared beliefs, goals and hard work of the C&D subgroups, regional C&D representatives plus many of our supportive peers and allies.

of the Parents in Surgery group at RCSEng, working on improving support for surgeons with parental responsibilities, including flexible training15. The BOTA website provides an ever-growing resource of lived experience and signposting to relevant services. The BOTA Committee introduced a Culture & Diversity (C&D) Representative full committee member as a permanent role in its 2021-22 Committee. Together with the BOTA WinS Representative, Vice President and President, the BOTA C&D subgroup was set up. In 2021, the BOTA C&D subgroup met with the BOA President and proposed establishment of the BOA & BOTA C&D Champions. The proposal was approved by the BOA Council, and elections for the C&D Champions were held in early 2022, with one junior and senior C&D Champion appointed from each region. The C&D Champions programme is currently the largest diversity, equity & inclusion (DEI) initiative in surgery in the UK. BOTA organised the inaugural C&D Champions Day at the RCSEng in April 2022, which was a successful event and marked a milestone for diversity and culture change in orthopaedics in the UK. The C&D Champions continue to advocate and promote DEI at a regional and national level, and are at the heart of the movement for change in orthopaedics.

This year, the BOA & BOTA Culture & Diversity Day was again held at the RCSEng on 21st July 2023, but this time was open to all, and focused on showcasing the diversity within the orthopaedic community, with a particular focus on disability and neurodiversity, with neurodivergent individuals providing insight into their challenges at work. The Professional Support Unit also spoke about different neurodiverse conditions and the support available, providing training for the C&D Champions to take back to their own regions. The rest of the day covered a wider breadth of diversity topics, including LGBTQ+ healthcare, pregnancy, maternity leave and returning to work less than full time, human factors, as well as the UK Black Surgical Experience and the British Association of Black Surgeons. There was also a discussion on the future BOA DEI strategy. The C&D Champions now sit on multiple regional and national DEI panels and working groups. They have delivered training on various topics at both trainee and senior levels, including mentorship, neurodiversity, including the BOA ‘Dyslexia in T&O Surgery’ webinar, and workshops on micro-aggressions. The C&D Champions in North West England presented the results of their ‘Harassment and Bullying Survey’ at the BOA Congress in September 2023, and others have been involved in the BOA national DEI Survey.

Trainee

Last year, the Wessex Champions arranged the first ‘Tips & Tricks for the Ergonomic Orthopod’ Course, which aimed at teaching students and junior trainees how to perform common orthopaedic procedures and manipulations, without the need for a larger stature or physical strength. The course was a great success and the second is currently in the pipeline.

Oliver Adebayo is currently a National Medical Director Fellow working for NHS England within the Getting Right First Programme. He is an out-ofprogramme ST8 registrar on the RNOH (Stanmore) rotation and the previous BOTA President for 2021/22. He is passionate about championing diversity and sustainability within orthopaedics.

Abhinav Singh is the current BOTA President. He is an ST5 registrar in the North West Thames Deanery and a NIHR Doctoral Fellow at the University of Oxford. He is a member of BOTA’s Culture & Diversity subgroup and works to ensure that orthopaedics remains inclusive for all.

Work aiming to engage people from diverse backgrounds into orthopaedics from an earlier stage is also underway. The British Hip Society (BHS) has set up a Schools Engagement Programme16, led by a BOTA C&D subgroup Committee member, and has delivered two school engagement sessions to date: one in Edinburgh at their Annual Meeting and another at this year’s BOA Annual Congress, with faculty including C&D Champions, BOTA Committee, local trainees and medical students. Plans are in place for the BHS Congress Schools Engagement session in Belfast in 2024, and the BOA are looking to make the Schools Engagement session a permanent feature, led by the C&D Champions. Similar work has also been done on a smaller scale in different regions, including in London with both BOA and BOTA Committee members attending the St Marylebone CE School NHS Careers Day. WinS and neurodiversity talks are occurring increasingly frequently at medical schools and WinS school projects have been organised by BOTA Committee members. Our C&D Champions are also involved in the BOA Toolkit group, developing a similar outreach programme for pupils from state schools to consider medicine as a career.

C&D Day Attendees.

Through a variety of initiatives and projects, including the establishment of C&D Champions, BOTA and BOA have placed DEI at the heart of our strategy. Our C&D Champions are a network of passionate advocates, who promote the representation and inclusion of minority groups within orthopaedics, providing a safe space and support for its members. Orthopaedics as a profession must continue to lead on driving positive culture change, to attract more diversity and talent into the specialty and to retain our current colleagues. n

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

C&D Day Attendees.

Medico-legal

Intra-operative breakage of instrumentation during orthopaedic surgery Shyam Kumar and Simon Britten

ontemporary trauma and orthopaedic surgery techniques involve the use of robust tools such as drills, reamers, hammers and chisels, alongside less durable instruments such as guidewires and Kirschner wires, used either to place cannulated screws, to guide reaming of the intramedullary canal, or to fix fracture fragments, either temporarily or definitively.

Shyam Kumar is a Consultant Orthopaedic Surgeon based at the Royal Lancaster Infirmary. He has completed an LLM in Medical Law and Ethics with Merit. His other roles include; Member of the BOA Medico-legal Committee, Clinical Assessor-PPA (Formerly NCAS) and Member of Appointments Advisory Committee, Royal College of Surgeons of England.

Given the light manual nature of orthopaedic procedures, it is inevitable, despite maximal care and good surgical technique, that occasional breakage of instrumentation may occur in the operating theatre. The majority of breakages tend to be drill bits or wires, with breakage occurring during fracture fixation. When breakage does occur, orthopaedic surgeons accept in broad terms that there is a balance to be considered – the risk of leaving the broken instrumentation in situ, weighed against the potential risks of attempted removal. Such considerations may be guided by whether the broken metal is deeply embedded in bone or protruding, the anatomical site of surgery including any adjacent neurovascular structures or joint surfaces, the nature of the retained metal – smooth K-wires and guidewires may have a propensity to migration, and the estimated additional surgical damage and risk of iatrogenic fracture if an embedded fragment of metal were to be pursued. Of lesser concern is the old adage ‘nobody ever looks good removing metalwork’. Consideration must also be given to the additional surgical time in light of any anaesthetic concerns, and also the fact that subsequent bone healing and callus formation may render later removal even more difficult. There is a relative paucity of studies on this topic, and to our knowledge no specific guidance exists from professional bodies in the UK and Ireland.

Consideration of the literature A study involving 12,601 cases, (Haberal et al. 2021)1 reported that the breakage of an orthopaedic instrument occurred in 0.28% of procedures, with a rate of 0.64% in fracture fixation procedures and 0.08% in elective orthopaedic surgery. Overall the rate of instrument breakage was 7.44 times higher in trauma cases than in elective surgery cases (p = 0.001). In their study, the broken instrument was a K-wire in 16 (44.4%) cases, a screw in 14 (38.9%), and a drill bit in six (16.6%). They found that retained broken instrumentation tended not to have long term adverse health effects or patient outcomes. The commonest wire to break in this study was the guide pin for cannulated screws. As a recent study, the trend towards cannulated screw guide pins may reflect increased usage of cannulated screw systems over time. An older prospective multi-centre study found the incidence of instrument breakage to be 0.35% (Pichler et al. 2008)2. Of note, the authors could not find any significant correlation between the surgeons’ experience and the rate of instrument breakage. Among the 42 cases of instrument breakage, 36 of them were buried safely in bone and none of these patients had any symptoms during the follow-up period. Loose drill bits and K wires were removed, as were wires lying in a joint. Given the absence of symptoms from metal buried deeply in bone, the authors concluded that removal of broken drill bits was not routinely indicated if securely embedded in the bone and is distant from blood vessels or nerves. They recommended removal of broken drill bits when loose, if both cortices of the bone are penetrated, there is proximity to a vessel or nerve, or if it lies in or near a joint. They recommended removal of smooth K wires given their known tendency to migrate.

Medico-legal

Simon Britten is a Consultant Trauma and Orthopaedic Surgeon in Leeds specialising in lower limb reconstruction. He is the President Elect of the British Limb Reconstruction Society and Chair of the BOA Medico-legal Committee.

Another two-year study looked at 7,775 procedures (Price et al. 2002)3. They found an instrument breakage rate of 0.18% of mixed trauma and elective cases (0.79% of trauma cases and 0.03% for elective cases). 11/14 breakages were broken drill bits. In seven cases the broken bit was left in situ. They noticed a higher incidence of breakages during fixation of fractures of the distal humerus. The authors concluded that overall any persisting harm to patients was negligible in such cases. However, they emphasised that when such instrumentation breakage occurred, there was scope for improvement in both documentation and the explanation (if any) given to the patient. In contradistinction to Pichler et al’s study above, Price found that of the 14 breakages identified in 12 cases, only one case had a consultant as lead surgeon, with 8/12 where the lead surgeon was a less experienced Specialist Registrar. Continuing the theme of drill bits in particular breaking, another two-year study of 8,132 patients, demonstrated a total of 30 (0.36%) cases of intra-operative instrument breakage, of which the majority were drill bits

(Dharmshaktu et al. 2020)4. Hirt et al.5 reported a frequency of three drill bit failures per 1000 internal fixations (0.3 %). They found the highest incidence during fixation of proximal femur fractures. The authors advised that a broken drill bit which is not in contact with an implant can be left in the body without any risk of delayed recovery. They recommended removal if the drill fragment is situated near a joint or if it can be easily removed without further trauma to the bone. They also suggest that once the fracture has healed the broken drill bit should be removed along with the implant provided no exceptional difficulties are involved. Migration of drill bits have been reported after fixation of acetabular fracture (Jamot et al. 2011)6. Broken wires or drill bits around the hip or pelvic cavity require particular attention and removal due to the risk of migration into the pelvis (Garabadi and O’Brien 2021)7. It remains to be seen whether the introduction of newer fixed angle locking plates have any effect on the incidence of drill bit breakage reported in the literature. >>

Intra-operative images 1a and 1b show an Ilizarov frame in situ. Distally a circular cortical defect can be seen after overdrilling and removing a broken drill bit, which had been used to begin a De Bastiani corticotomy of the proximal tibia. On balance it was considered necessary to remove the broken drill bit and to move the corticotomy site slightly more proximal, to avoid interfering with new bone formation during distraction osteogenesis of the proximal tibia. Images 2a and 2b at 19 months, prior to discharge show a more proximal column of regenerate bone which has healed and recorticated satisfactorily. More distally the circular defect in the anterior tibial cortex persists, but the rest of the cylindrical overdrilling track in the intramedullary bone has filled in and healed.

Medico-legal

Even in some cases where the instrumentation has not broken, previously clavicle fracture fixation with K wires gave rise for concern regarding the uncanny ability of the wires to migrate – for example to the spinal cord (Fransen et al. 2007)8, to the oesophagus and brachiocephalic artery (Wada S, Noguchi T, Hashimoto T et al. 2005)9, to the lungs (Hegemann et al. 2005)10, and to the ascending aorta (Nordback I, Markkula H 1985)11. These reports are thankfully of historical interest only with the advent of improved surgical techniques for clavicle fracture fixation, but emphasise the need to be wary of migration of wires – both intact and broken – at certain anatomical sites.

Medico-legal considerations

surgery is in the region of 0.3%. The rate of breakage is higher in trauma than elective surgery. Authors tend to agree that broken instrumentation which is well embedded and fixed in bone is unlikely to cause any problems and can be left in situ. Broken instrumentation particularly in the clavicle or pelvis may require removal due to risk of migration and subsequent injury to neurovascular structures. The same applies to loose metal threatening other adjacent structures, including the articular surface of a joint.

“It should go without saying that good surgical technique must be employed at all times to minimise the risk of breakage of instrumentation, and the operating surgeon should be well versed in the techniques of broken metalwork removal, including but not limited to use of the broken screw removal set.”

From the literature available, the average rate of breakage of a drill bit or wire during trauma and orthopaedic

Intra-operative breakage of instrumentation should be explained as a material risk during the consent process for surgery. It should be explained that well seated and embedded broken drill bits and wires can be left in situ without retrieval, with no significant adverse consequences.

In the event of an intra-operative instrumentation breakage, appropriate documentation should be made in the operation note, including the weighing up process considering factors in play both for and against broken metal retrieval. The patient should be fully informed as soon as is practicable to do so, ideally when no longer under the effects of the general anaesthetic. It should go without saying that good surgical technique must be employed at all times to minimise the risk of breakage of instrumentation, and the operating surgeon should be well versed in the techniques of broken metalwork removal, including but not limited to use of the broken screw removal set. Knowledge of case reports of other available novel techniques described to remove broken instrumentation may also be of use, for example Lim JW, McMillan TE, Stevenson IM 202112. From a governance perspective, when formulating local policies, broken orthopaedic instrumentation identified intra-operatively and intentionally left in situ, should be clearly differentiated from inadvertent retained surgical instruments left in body cavities. n

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

Subspecialty

Why things hurt? Shifting the paradigm on chronic pain Shefali Kadambande

A Dr Shefali Kadambande began a career in Medicine in 1987 in Mumbai, India. She was one of the first in Wales to be awarded the FFPMRCA by the Faculty of Pain Medicine and is currently practising as a Consultant at the Teaching University Hospital of Wales, Cardiff. She is also a member of the British Pain Society, Royal College of Anaesthetists and features on the specialist register of the GMC. Dr Kadambande has a special interest in neuropathic pain, headaches, facial pain, postsurgical persistent pain, pelvic pain and complex regional pain syndrome amongst other chronic pain conditions. She has been the local pain medicine educational supervisor for the advanced pain management trainees for almost 10 years. Throughout her career she has focussed on service development and started Qutenza and External neuromodulation clinics in Cardiff which are innovative for Wales.

s Mahatma Gandhi once said “You must be the change you wish to see in the World”. It defines my journey in pain management over the last two decades. Pain unlike some health conditions is not visible and often doesn’t get the attention it deserves. It may come as a surprise to some readers that the definition of pain itself includes the emotional dimension. Pain medicine is a relatively young speciality and despite awareness campaigns by the British Pain Society it still has a long way to go for public recognition. Often, patients and their referrers are completely unaware of the remit of their local pain management services. The British Pain Society and Faculty of Pain Medicine have produced useful resources for patients and healthcare providers on medications such as Gabapentin, Pregabalin, Amitriptyline and other aspects such as ‘Managing pain after your surgery’, and ‘Understanding and managing your long-term pain’. Pain is one of the commonest reasons to visit the GP and affects 1 in 4 people. Between a third and one half of the UK population is affected by chronic pain and 10% - 14% have moderate to severely disabling pain and struggle to participate in daily activities. The prevalence increases with age: 30% in 18-39 year olds and 62% in the over 75s. The most common types of pain are back pain, headache and joint pain due to an ageing population and increasing arthritis. It is well known that chronic pain affects an individual’s ability to function, their sleep pattern, mood and emotions thereby resulting in a much bigger impact upon society. I hope that by reading the articles in this section, I can enthuse you to explore this topic further and encourage you to talk to your local pain management team earlier with your complex cases. Reviewing the anatomy and physiology of pain pathways is important to understand the principles of ‘Why things hurt’. So, the next time you might think ‘It is all in the head’, I hope you

will recall the thalamocortical affective influence. It may not be surprising for those of you who deal with chronic postsurgical pain (CPSP) that many factors contribute to its pathogenesis including the patient’s emotional and psychological status, preexisting painful conditions and central sensitisation, pre-operative opioid intake and the severity of their post-operative pain. Therefore a careful patient selection and being vigilant in recognising the risk factors is important to minimise the burden upon health resources later. The classification of pain into nociceptive, neuropathic and nociplastic categories reflects the evolving understanding of the pathophysiology of pain. Complex regional pain syndrome (CRPS) remains the highest concern for most orthopaedic surgeons, and is an example of nociplastic pain. I hope the article on CRPS can give you some reassurance. A team effort is essential in managing all aspects of care including physical therapy, psychological support, patient education and pain modulation. I envisage a future of collaborative patient centred care in the form of prehabilitation including opioid management prior to surgery, transitional pain clinics, and an emphasis on prevention rather than management of chronic pain. I am grateful to my colleagues for their contribution and expertise within the articles which will hopefully help the readers understand and manage their patients more effectively. In conclusion, in the words of Henry Ford: “Coming together is a beginning, staying together is progress and working together is success”. n

The National Joint Registry (NJR) collects information on joint replacement surgery and monitors the performance of joint replacement implants. One key function of the NJR is to monitor the performance of implants used in joint replacement. Another important function is to monitor the performance of surgeons and hospitals to help improve patient outcomes. The NJR is recruiting for a number of key positions to support this work:

• Chair - NJR Surgical Performance Committee • Vice Chair - NJR Surgical Performance Committee • Vice Chair - NJR Implant Scrutiny Committee For further information and details of the person specification and responsibilities of the roles, please visit https://zurl.co/94CK The closing date for applications is 12 January 2024.

Subspecialty

Why does it hurt? An overview of pain mechanisms Neeraj Saxena

nderstanding the underlying anatomical and neurochemical mechanisms of pain is critical in optimising clinical outcomes, prevention of chronic pain and associated suffering, and novel analgesic development.

Professor Neeraj Saxena is a Consultant in Pain Medicine and Anaesthetics at Cwm Taf Morgannwg University Health Board, with an interest in musculoskeletal and lifestyle medicine. His research interests are understanding the brain mechanisms of pain perception and improving clinical outcomes of various pain therapies.

In the year 2020, for the first time since 1979, the International Association for the Study of Pain revised the definition of pain as “an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage”. This was further expanded upon by the following six keynotes: 1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors. 2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons. 3. Through their life experiences, individuals learn the concept of pain. 4. A person’s report of an experience as pain should be respected. 5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being. 6. Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain. Pain is generally considered to be body’s protective response or alarm system which facilitates avoidance from injury or protection of an injured body part during the healing process. Acute pain typically follows traumatic tissue

injuries, is well characterised, limited in duration, while improving with time and tissue healing. However, sometimes the body’s alarm function is lost and chronic pain may develop, which can linger on and often presents a significant level of distress. Chronic pain may have a gradual or distinct onset, often persists beyond three to six months of expected healing/resolution, serves no protective response and can be refractory to treatments. The temporal distinction between acute and chronic pain has arbitrarily been defined as a period of greater than three months, however it is increasingly recognised that the transition from acute to chronic pain can take place over the course of a few weeks to a few months, essentially depending on the expected trajectory of recovery. Some authors have suggested the category of subacute pain as pain lasting over six weeks but under three months. One of the earliest scientific models for explaining pain was provided by Renee Descartes (Cartesian dualism theory) which suggested pain to be a mutually exclusive entity caused by either physical or psychological injury. Over time, especially through the work of Joseph Bonica and John D Loeser, the understanding of pain is better explained as a biopsychosocial phenomenon (Biopsychosocial model) wherein one’s overall, usually complex, pain experience is the result of an interplay between nociception, (the neural process of encoding noxious stimuli), with their psychological factors (thoughts and behaviours), and their social circumstances and past experiences. It is commonly seen that people who tend to catastrophise, have a fear avoidance attitude towards rehabilitation, lack social support or healthy lifestyles are likely to experience greater pain and poorer recovery, for example, after a knee replacement surgery, than people for whom these psychosocial factors do not apply.

Subspecialty

Pain pathways, unlike other sensory pathways, are not modality-specific, hard-wired systems, but are dynamic such that the output (response) to the input (stimulus) is variable, accounting for the theoretical systems which explain the clinical and neurophysiological observations, in acute and chronic pain. Nociceptors are receptors including free nerve endings which respond to thermal and mechanical stimuli and are distributed throughout the body including skin, viscera, joints, muscles and meninges. Some of these nociceptors (silent nociceptors), while providing continuous information about the tissue environment tend to be refractory to mechanical and electrical stimuli. However, in the presence of chemical mediators of inflammation they become active, converting the signals into electrical impulses (transduction) and facilitate transmission of the signals. This transmission occurs through the primary afferent fibres, A-delta and C, which differ in terms of their microscopic structure and velocity of conduction of electrical impulses. Figure adapted from Chen Y. and Abdi, S. 2022. Basic Science: Pain Mechanisms and Pathways. In: Banik, R. K. (ed.) Anesthesiology A-beta fibres, being highly myelinated In-Training Exam Review: Regional Anesthesia and Chronic Pain. Cham: Springer International Publishing. and large in diameter facilitate rapid signal conduction in response to touch and non-noxious stimuli. A-delta fibres, being lightly myelinated and smaller and largely contribute to pain localisation. at the dorsal horn. Gate-control theory, in diameter, conduct slower than A-beta and Some fibres project to the periaqueductal proposed by Melzack and Wall, implies that respond to mechanical and thermal stimuli, grey (PAG) matter, which is involved in both non-painful stimuli from the periphery, typically causing the initial pain response pain modulation. The fibres within the transmitted by A-beta fibres and descending to acute pain. C fibres, spinoreticular tracts inhibitory cortical pathways would block being un-myelinated and also crossover to reach the nociceptive pathway at the dorsal horn. smallest in diameter are the brainstem reticular This theory helps explain our reflex response the slowest conductors, formation and from there of ‘rubbing away pain’ wherein rubbing and respond to a wide on to the thalamus and stimulates the A-beta fibres to stop pain range of chemical, hypothalamus. With signals propagating. Clinical application of mechanical and thermal the multiple cortical this occurs in a range of non-pharmacological stimuli, typically leading projections these fibres are techniques such as TENS (transcutaneous to slow burning type generally involved in the electrical stimulation), massage, acupuncture, pain. These fibres travel emotional aspect of pain. or even invasive options such as spinal through the sensory Key brain areas involved cord stimulation. Descending pathways, nerves and synapse with in pain processing have especially from the PAG and rostroventral the second-order neurons been identified particularly medulla (RVM) project serotonergic and in the dorsal horn of the through functional noradrenergic signals to the spinal cord spinal cord. neuroimaging tools like inhibitory interneurons (diffuse noxious functional MRI and PET inhibitory control). This supraspinal pain Once in the dorsal horn scans. This so-called modulation can either amplify or inhibit these fibres transmit their pain matrix includes the transmission of pain related signals. Increased information to the brain, primary and secondary activation of the ‘ON’ cells in the RVM through the spinothalamic somatosensory (S1 and S2), facilitate increased pain transmission to the (predominant) and insular, anterior cingulate brain, while ‘OFF’ cells inhibit transmission. spinoreticular pathways. cortex and prefrontal Indeed, this mechanism is exploited in Within the spinothalamic cortex, and the thalamus. pharmacological neuro-modulation through tract, these second-order opioidergic, serotonergic and noradrenergic neurons crossover to the other side within The overall output of the fibres in the drugs, and non-pharmacological neuroa few segments, ascend as the contralateral spinothalamic tract depends on the net balance modulation like meditation, or cognitivespinothalamic tract to the thalamic nuclei, between the facilitatory and inhibitory signals behavioural therapy. >>

“One of the earliest, scientific models for explaining pain was provided by Renee Descartes (Cartesian dualism theory) which suggested pain to be a mutually exclusive entity caused by either physical or psychological injury.”

Subspecialty

Based on the pathophysiology described, chronic pain may be classified in the following three categories: 1. Nociceptive (or inflammatory), 2. Neuropathic or 3. A newly defined class of Nociplastic pain. While considered distinct classes, it is acknowledged that a combination of these may co-exist within a single individual.

The pain pathways described are activated in conditions producing acute pain, which are expected to settle once symptoms resolve over time. Often prolonged nociception outlasts its usefulness, resulting in changes within the different limbs of this pathway and the pathogenesis of chronic pain. Sensitisation may occur peripherally (at the level of the nociceptors; peripheral sensitisation) and centrally (at the level of the dorsal horn; central sensitisation) contributing to the development of chronic pain. Increased responsiveness and reduced sensitivity of peripheral nociceptors primarily due to persistent inflammatory stimulation through chemicals including H+, K+, bradykinin, serotonin, prostaglandins and neurokinins results in the development of primary hyperalgesia (increased pain response to a stimulus that normally provokes pain, tested clinically through pinprick and compared with adjacent or contralateral areas). Such peripheral sensitisation can also affect A- beta fibre functioning to inhibit pain transmission. Strong activation of nociceptive afferents, particularly C-fibre nociceptors may lead to sensitisation of dorsal horn neurons (windup phenomenon). This involves a combination of mechanisms such as an increased receptive field size, lower neuronal firing thresholds, increased magnitude of action potential discharges and increased spontaneous impulse activity; akin to turning up a sound system amplifier. These pathophysiological changes result in clinically

observed features of secondary hyperalgesia (increased pain sensitivity to adjacent uninjured area); allodynia (painful response to non-noxious stimuli); and spontaneous pain. Patients reporting painful sensations when clothes rub against their skin, or shaving the area, gentle touching or pressing on the area or even contact with mildly warm or cold objects, are all clinical manifestations of allodynia. Further long-term potentiation occurs due to repetitive activation of highthreshold C fibres which result in increased strength of their synaptic connections with dorsal horn neurons. NMDA subtype of glutamate receptors and the substance P receptors (NK1) play a key part in such longterm potentiation. Supraspinal mechanisms also contribute to the development of central sensitisation. Reduction in central inhibitory outflow causes spinal hyper-excitability through reductions in efficacy of GABAergic and glycinergic transmission. In addition, activation of astrocytes and microglia occurs through neuronal signals including substance P, glutamate and fractalkine which promotes central sensitisation, directly through release of pro-inflammatory cytokines and indirectly through reducing efficacy of GABAergic inhibition. As stated previously, this forms a key target for modulation through both pharmacological and non-pharmacological tools.

Nociceptive pain, particularly if somatic, follows a typical dermatomal pattern, often proportionate to degree of inflammation, and reflects activity related to the nociceptors. Examples include trauma, surgery, infection and arthritis. Nociceptive pain arising from the internal organs (visceral pain) occurs due to smooth muscle distension, or contraction, stretching of the capsule around an organ, ischaemia, necrosis and/or chemical inflammatory process. Visceral pain tends to be diffuse, poorly localised and often described as deep, dull and dragging. Such pain is often associated with a strong autonomic response (nausea, vomiting, heart rate and blood pressure changes). Pain may be referred to distant sources due to convergence of different afferents on the same dorsal horn neurones (for example, shoulder pain following laparoscopic surgery due to diaphragmatic stretching). Neuropathic pain occurs due to a lesion or disease of the somatosensory system, for example, post-surgical, trigeminal neuralgia, post-herpetic neuralgia, diabetes, HIV, chemotherapy associated pain or nerve entrapment. Central causes include conditions such as multiple sclerosis, spinal cord injury and stroke. The typical characteristics of neuropathic pain are those of secondary hyperalgesia and allodynia. It is now understood that pain may arise from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain. This has been classified as Nociplastic pain and applies to conditions such as fibromyalgia, complex regional pain syndrome, irritable bowel syndrome and mechanical back pain. There still remain a lot of un-answered questions, such as why individuals differ in their pain experience, how acute pain transitions to chronic pain, and why individuals differ in their susceptibility to analgesics. However, the progress in our understanding of pain mechanisms has helped pain specialists apply multimodal tools including analgesics and non-pharmacological therapies ranging from simple interventions to the more invasive ones such as spinal cord or deep-brain stimulation while exploring pre-emptive opportunities to prevent sensitisation/chronicity. n

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Subspecialty

Complex regional pain syndrome (CRPS) Sunil Dasari

omplex regional pain syndrome (CRPS) is a syndrome characterised by a non-dermatomal distributed, severe, continuous pain in the affected limb and is associated with sensory, motor, vasomotor, sudomotor, and trophic disturbances1.

Sunil Dasari is an Anaesthesia and Pain Medicine Consultant at University Hospital of Wales, Cardiff. He is Chair of the working group for All Wales Guidelines on Opioids for Chronic Non-Cancer Pain for Adults. Sunil is a Faculty Tutor for the Faculty of Pain Medicine, Lecturer at Cardiff University and Vice Chair of the Welsh Pain Society.

When there is tissue damage like after trauma or surgery, we experience pain which will subside once the healing process is completed without many features of autonomic dysfunction. In CRPS we see that the pain is not only disproportionate to the injury but is also associated with changes related to autonomic dysfunction. CRPS is mostly precipitated after trauma or surgery. Upper limbs are more commonly affected than lower limbs1. The incidence is 5-26 / 100,0002. CRPS can occur in anyone at any age, with mean age of diagnosis peaking at 40-50 years2. It is reported 3-4 times more frequently in females than in males2. Less than 10% of patients with CRPS report no causal injury or trauma2.

Different pathophysiologies include2: • Hyperactivity of the sympathetic nervous system and vasomotor disturbance. • Neurogenic inflammation. • Deep tissue microvascular pathology. • Autonomic dysregulation and small fibre neuropathy. • Central processes including cortical reorganisation. • Genetic predisposition. • Psychological factors contributing like Depression, PTSD etc.

Differential diagnosis3 • Infection (bone, soft tissue, joint or skin), orthopaedic mal fixation. • Joint instability.

There are two types of CRPS, type 1 where there is no distinct demonstrable nerve lesion, and type 2 where a demonstrable nerve lesion is present.

• Arthritis or arthrosis, bone or soft tissue injury (including stress fracture, instability or ligament damage), compartment syndrome, neural injury (peripheral nerve damage, including compression or entrapment neuropathy, or central nervous system or spinal lesions).

The available evidence suggests that transient CRPS is common after limb fractures and orthopaedic operations (up to 25% of cases)3. The pain improves in most cases and CRPS lasting longer than a few months is an uncommon condition (the overall prevalence is less than one in 1,500), although even a transient episode of CRPS may give rise to long-term disability due to structural and/or functional changes3.

• Thoracic outlet syndrome (due to nerve or vascular compression), arterial insufficiency (usually after preceding trauma, atherosclerosis in the elderly or thromboangiitis obliterans (Buerger’s disease),Raynaud’s disease, lymphatic or venous obstruction, Gardner–Diamond syndrome, brachial neuritis or plexitis, erythromelalgia (may include all limbs) and self-harm.

Pathophysiology

How do we diagnose CRPS?

The pathophysiology is multifactorial with the most commonly accepted one described as exaggerated inflammatory response with autonomic nervous system dysfunction.

It is a clinical diagnosis as there is no single test which can confirm CRPS. It is diagnosed as pain developing after an initial inciting event with allodynia or hyperalgesia out

Subspecialty

of proportion for the inciting event. This would include evidence of skin changes, sudomotor dysfunction, or oedema and the absence of any other cause which would otherwise explain the presenting signs and symptoms.

and tremors or jerking. These can reflect secondary spread of disturbed neural activity to the brain and spinal cord. Most resolve by themselves during healing, but some people require orthopaedic surgery to lengthen contracted tendons and restore normal flexibility and position.

Budapest criteria for diagnosis of CRPS1

Management of CRPS

This is considered as continued pain that is disproportionate to any inciting event or there is no other diagnosis which explains the patient’s signs or symptoms.

Prompt diagnosis and early treatment are considered best practice in order to avoid secondary physical problems associated with disuse of the affected limb and the psychological consequences of living with undiagnosed chronic pain3.

The patient must report at least one symptom in three of the following four categories and at least one sign in two of the following four categories:

Practitioners can support patients by providing a clear diagnosis, information and education about the disease, helping to set realistic goals and, where possible, involving the patient’s partner and/or other family members3.

1. Sensory: allodynia and or hyperalgesia. 2. Vasomotor: temperature asymmetry and or skin colour changes / colour asymmetry. 3. Sudomotor: oedema and / changes in sweating / sweating asymmetry.

CRPS of the left hand.

4. Motor or trophic: decreased range of motion and / motor dysfunction and / changes in hair and nail.

Clinical features4 Unprovoked or spontaneous pain that can be constant or fluctuate with activity. Excess or prolonged pain after use or contact. Burning or pins and needle sensation, or as if the affected limb was being squeezed. Allodynia, in which light touch or normal physical contact is very painful. Hyperalgesia where severe or prolonged pain after a mildly painful stimulus such as a pin prick. Changes in skin temperature, skin colour, or swelling of the affected limb. The injured arm or leg may feel warmer or cooler than the opposite limb. Skin on the affected limb may change colour, becoming blotchy, blue, purple, grey, pale, or red. These skin symptoms typically fluctuate as they indicate abnormal blood flow in the area. Changes in skin texture over time. Insufficient delivery of oxygen and nutrients can cause skin in the affected limb to change texture. In some cases, it becomes shiny and thin, in others thick and scaly.

Changes in sweating and nail and hair growth. On the affected limb, hair and nails may grow abnormally rapidly, or not at all. Patches of profuse sweating or no sweating may occur. All are under neural control and influenced by local blood circulation. Stiffness in affected joints. Reduced movement leads to reduced flexibility of tendons and ligaments. Tight ligaments or tendons sometimes rub or pinch nerves to provide an internal cause of CRPS in people who do not have external injuries.

Physical/occupational/psychological therapy1: A multidisciplinary approach including rehabilitation with physical therapy (PT), occupational therapy (OT), and psychological therapy. Because of the extremity pain in CRPS, patients tend to avoid the use of the affected limb and generate fear associated with the pain. With the use of PT and OT, the goal is to have the patient improve the function and the range of motion of the extremity and achieve reduction in pain and increased mobility.

“There is no single test which can confirm CRPS. It is diagnosed as pain developing after an initial inciting event with allodynia or hyperalgesia out of proportion for the inciting event.”

Muscle atrophy. In affected limbs, bones that receive signals from the damaged nerves rarely become affected. However, most patients report reduced ability to move the affected body part often resulting in disuse osteopaenia visible on a plain X-ray. This is usually due to pain and abnormalities in the sensory input that help coordinate movement. Rarely patients report abnormal movement in the affected limbs, fixed abnormal posture like dystonia

With severe pain, patients will experience significant emotional distress. Psychological therapy can be helpful to assist patients with coping mechanisms for pain, relaxation training, thermal biofeedback and graded exposure therapy.

The role of PT, OT and psychological therapy is to improve function, mobility, quality of life and the ability to manage one’s own pain. In CRPS, these therapies should be utilised early and are considered by many pain specialists to be the first-line treatment1. Neuropathic pain medications: The basis of using neuropathic pain medications to treat CRPS is based on their usefulness in treating other neuropathic conditions. >>

Subspecialty

Amputation in CRPS3 Amputation may be considered in rare cases of intractable infection or fixed deformity of the affected limb. Surgery should be avoided on a CRPS-affected limb where possible and be deferred where it cannot be avoided until one year after the active process has resolved. Surgery may be indicated in CRPS type 2 when there is an identifiable remediable nerve lesion (for example certain cases of neuropathic pain due to either nerve compression by scar tissue, neuroma formation or peri-operative nerve injury, such as through a needle stitch) but should be undertaken only when the expected benefit from pain reduction outweighs the risk of exacerbation. Where surgery on an affected limb is necessary, this should ideally be performed by a surgeon with experience in operating on patients with CRPS and an anaesthetist who is also a pain specialist3.

Key learning points 1. CRPS is a clinical diagnosis and other causes of pain (e.g. infection) should be excluded. 2. Budapest criteria is useful in establishing diagnosis. 3. Early commencement of physiotherapy and medical treatment (e.g. neuropathic agents) can improve outcome. 4. When considering surgery for Type 2 (nerve injury) there should be a thorough discussion of pros and cons with the patient. Right foot of an individual with complex regional pain syndrome.

RCTs in children with CRPS have shown improvement in pain and sleep with Amitriptyline and Gabapentin1. Anti-inflammatory medications: Nonsteroidal anti-inflammatory medications with their anti-inflammatory action has a role in the acute phase of the syndrome1. Bisphosphonates: Pamidronate (single 60 mg intravenous dose) should be considered for suitable patients with CRPS less than six months in duration as a one-off treatment3. Spinal cord stimulator (SCS): There is good evidence to support the use of SCS in CRPS1. It should be considered early and not as a therapy of last resort. Dorsal Root Ganglion (DRG) stimulation1 may prove to be the more superior neuromodulation option for CRPS, as DRG can target specific painful areas of the limbs.

Recommendations for orthopaedic surgeons3 Orthopaedic surgeons should be aware of the diagnostic criteria for CRPS. They should

be aware that CRPS may never fully resolve and that it often severely reduces patients’ quality of life and may be associated with increased psychological distress. They should be aware that the diagnosis of CRPS can be made in patients who have only had a minor soft tissue injury. It may even occur without a traumatic event. A diagnostic checklist for use in an orthopaedic setting should be available in orthopaedic departments, including outpatient departments and plaster rooms. Physiotherapy and/or occupational therapy, unless contraindicated, should be initiated immediately when CRPS is suspected. The orthopaedic team should initiate early treatment with simple analgesic drugs. Orthopaedic surgeons may initiate treatment with other drugs useful for neuropathic pain, such as tricyclic antidepressants (amitriptyline, nortriptyline or imipramine) and anticonvulsants (gabapentin or pregabalin), but the GP or pain specialist is usually best placed to arrange the follow-up required for drug titration and monitoring. An early referral to prevent chronicity and its detrimental effects is recommended.

5. Early referral to the pain service for medication titration, pain interventions and consideration of a spinal cord stimulator. 6. Amputation is an option in the presence of infection or fixed deformities but warrants careful discussion with the patient and a multi-disciplinary input. n

References 1. Shim H, Rose J, Halle S Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth. 2019;123(2):e424-e433. 2. Young-Do Kim. Diagnosis of complex regional pain syndrome. Ann Clin Neurophysiol. 2022;24(2):35-45. 3. Royal College of Physicians (2012). Complex regional pain syndrome in adults UK guidelines for diagnosis, referral and management in primary and secondary care. Available at: www.rcplondon.ac.uk/file/1589/download. 4. National Institute of Neurological disorder and stroke. Complex Regional Pain Syndrome. Available at: www.ninds.nih.gov/healthinformation/disorders/complex-regionalpain-syndrome. [Accessed October 2023].

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Subspecialty

Chronic postsurgical pain: An inevitable consequence of surgery or preventable disease? Edward Keevil

T Edward Keevil is a Consultant in Anaesthetics and Pain Management at Somerset NHS Foundation Trust. He works in chronic pain management for the Somerset Community Pain Management Service and is clinical lead for acute pain at Musgrove Park Hospital, Taunton, Somerset. He is a tutor for the Postgraduate Diploma in Pain Management at the University of South Wales.

he concept of chronic postsurgical pain (CPSP) as a discrete condition has its origins in the early 1990s. At this time a survey of pain services in the North of England and Scotland identified that 20% of attendees to pain clinic attributed the onset of their pain, at least in part, to surgery1. Almost 30 years later CPSP was included in the International Classification of Diseases, Eleventh Revision (ICD-11) as a disease in its own right2. The ICD-11 definition of CPSP states:

CPSP is an example of the transition from acute to chronic pain. Established CPSP is challenging to treat and efforts to reduce the burden of this disease focus on prevention. Current models of care aim to identify patients at risk of CPSP early in the surgical pathway, to optimise patients prior to surgery, to devise individualised peri-operative analgesic plans, and to manage pain in the acute post-operative period and beyond discharge.

“Chronic postsurgical or post traumatic pain is pain developing or increasing in intensity after a surgical procedure or a tissue injury (involving any This approach was pioneered in Toronto, trauma including burns) and persisting beyond the Canada, where it was termed a ‘transitional healing process, i.e. at least 3 months after surgery pain service’ and similar models are or tissue trauma. The pain is either localized to increasingly being incorporated into perithe surgical field or area of injury, projected to the operative guidelines4. Recent examples include innervation territory of a nerve situated in this area, the Faculty of Pain Medicine ‘Surgery and or referred to a dermatome (after surgery/injury to Opioids’ document and guidance from GIRFT deep somatic or visceral tissues). Other causes of on ambulatory joint replacement surgery5,6. pain including infection, malignancy etc. need to be Neuropathic Pain Type of Surgery Any CPSP (%) Severe CPSP (%) excluded as well as pain (proportion) continuing from a Amputation 30-85% 5-10% 80% pre-existing pain problem”. One year after surgery the incidence of moderate to severe CPSP is 12% whilst the incidence of severe CPSP is 2%3. A significant proportion of this pain,

35-57%, is neuropathic pain. The incidence is comparatively high for certain orthopaedic operations, as shown in Table 1.

Hip Arthroplasty

27%

1-2%

Knee Arthroplasty

13-44%

15%

Table 1: Incidence of CPSP in common orthopaedic procedures. Source: Acute Pain Management: Scientific Evidence 5th Edition.

Subspecialty

Pre-operative opioid reduction Pre-operative opioid use is associated with a four-fold increase in the odds of CPSP and a reduction in preoperative opioid consumption by 50% is associated with improved outcomes, measured by WOMAC score at six months to 12 months followup, in patients undergoing hip and knee arthroplasty8,9. Patients who successfully weaned opioids had similar outcomes to those who did not use opioids preoperatively. This may prove one of the most effective strategies in the prevention of CPSP although the process of opioid reduction, even in a motivated patient, can take many months. Figure 1: An example of the structure of a transitional pain service.

An example of the transitional pain service model can be seen in Figure 1 and the remainder of this article examines the techniques used to prevent CPSP in more detail.

Pre-operative Strategies Early identification of patients at risk of CPSP Risk factors for CPSP are often categorised as pre-operative, intra-operative and postoperative and are summarised in Table 27. These risk factors are not independent of each other. For example, there is a clear link between anxiety, depression and chronic pre-operative pain.

Pre-operative

A risk prediction model has recently been developed and validated for chronic postsurgical pain in adults across a wide range of surgical specialities8. The model demonstrates that four easily obtainable predictors are necessary for reliable prediction of CPSP. These are: pre-operative treatment with opioids, bone surgery, numerical rating scale pain score on post-operative day 14, and the presence of painful cold within the area of surgery on post-operative day 14. Painful cold being a sign of post-operative neuropathic pain.

This risk prediction model is consistent with criteria used in current clinical practice. Referral criteria for the original transitional pain service in Toronto • Moderate to severe pain, lasting > 1month were pre-operative pain, with or • Repeat surgery without opioid use, and severe • Psychological vulnerability acute post-operative pain. Where • Anxiety referral to pain clinic prior to surgery is suggested in peri-operative • Female sex guidelines, it is often recommended • Younger age (adults) that patients with a history of • Worker’s compensation chronic pain or those taking high • Genetic Predisposition dose opioids are referred. • Opioid use (particularly if ineffective)

Intra-operative

• Surgical approach with risk of nerve damage

Post-operative

• Pain • Radiation therapy • Neurotoxic Chemotherapy • Depression • Psychological Vulnerability • Anxiety • Pain and anxiety trajectories

Table 2: Risk factors for the development of CPSP. Source: Acute Pain Management: Scientific Evidence 5th Edition.

Pre-operative psychological interventions The identification of psychological risk factors for the development of CPSP has led to interest in the use of peri-operative psychological interventions. A systematic review of cognitive behavioural therapy, relaxation therapy, or a combination of the two, demonstrated a reduction in the severity of CPSP at follow-up ranging from three to 30 months10. The treatment effect was comparable to some commonly used pharmacological interventions.

Intra-operative strategies Pharmacotherapy Gabapentinoids, ketamine, glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDS) and intravenous lidocaine all have the potential to reduce both acute post-operative pain and CPSP. Results from three meta-analyses over the last decade have been conflicting and further large randomised controlled trials are needed11-13. There are ongoing trials into peri-operative gabapentinoids (GAP study) and ketamine (rocKET trial). >>

“Current models of care aim to identify patients at risk of CPSP early in the surgical pathway, to optimise patients prior to surgery, to devise individualised peri-operative analgesic plans, and to manage pain in the acute post-operative period and beyond discharge.”

Subspecialty

Gabapentinoids have been widely used in enhanced recovery programmes for both their effect on acute pain and CPSP, however, they are associated with a 50-80% increase in the odds of respiratory complications when used in the peri-operative period for hip and knee arthroplasty14. It would seem prudent to use these agents only in those most likely to benefit until further research has been completed. Regional anaesthesia and local anaesthetic infiltration Peri-operative regional anaesthesia has been shown to reduce CPSP in many different types of surgery. A Cochrane review demonstrated a treatment effect for local anaesthetic infusion in iliac crest bone-harvesting15. There is limited evidence from meta-analyses for other orthopaedic procedures due to the heterogeneity of studies. It is, however, undeniable that regional and local anaesthesia have a profound effect on acute post-operative pain and in most areas where data is available regional anaesthesia does have a treatment effect for the prevention of CPSP. The use of regional anaesthesia in patients at risk of persistent post-operative pain is a widely accepted technique.

Post-operative strategies Acute post-operative pain management Acute post-operative pain is an established risk factor for CPSP and acute pain teams

play an important role in treating this. Current consensus on post-operative pain management accepts that focussing solely on pain intensity creates unrealistic expectations and drives opioid prescribing. Post-operative prescribing should enable early functional recovery whilst weaning medications as appropriate to prevent long term harms. Abnormal pain trajectories, such as increasing or unresolving pain, may indicate neuropathic pain, complications of surgery or psychological distress, all of which increase the risk of CPSP. Acute pain teams are uniquely placed to identify abnormal pain trajectories early. Psychological factors including anxiety, depression, poor coping skills and catastrophising are significant risk factors for CPSP and psychological intervention in the peri-operative period has been shown to reduce the incidence of CPSP9. The inclusion of psychologists in acute pain teams is a relatively new concept and at present few hospitals have this in place in the UK. Pain management in the outpatient setting The transitional pain service model aims to provide outpatient follow-up for the months following discharge from hospital. They provide ongoing psychological support, assistance with rehabilitation and medication management.

One such service, the Acute Pain Service Outpatient Clinic (APS-OPC), in Helsinki, Finland has shown promising outcomes. Patients received psychological interventions and physiotherapy for an average of 2.8 months. At discharge from hospital 54% of patients were taking weak opioids, 32% strong opioids and 71% gabapentinoids. At discharge from the APS-OPC 20% of patients were taking weak opioids, 6% strong opioids and 43% gabapentinoids16.

Conclusion The transitional pain service model has the potential to improve outcomes for patients who require orthopaedic surgery and are at risk of CPSP. There is a growing body of evidence for certain components of the transitional pain service and some, such as pre-operative optimisation of pain and opioid prescribing, are already included in orthopaedic peri-operative guidelines. Evidence for the transitional pain service as a whole is still limited and the extent to which these services can reduce the incidence of CPSP is yet to be seen. n

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

In Memoriam

Richard Montgomery 5 May 1955 – 28 August 2023 Obituary by William Eardley

rofessor Richard Montgomery died suddenly of a heart attack on Monday 28th August 2023, after a weekend with family at his cottage in the Yorkshire Dales. His loss is felt by many across the UK orthopaedic community and further afield. Richard was born in London in May 1955 and following his school years and early life in Tonbridge,

Asif Saifuddin

16 November 1959 – 19 August 2023 Obituary by Sajid Butt

r Asif Saifuddin joined the Royal National Orthopaedic Hospital as a consultant radiologist straight after completing his radiology training from Leeds in 1992. This was his only job application as a consultant radiologist that he would ever make. He was gifted with a rare to be found clarity of thought and singleminded sense of purpose. An avid reader, he had an encyclopaedic memory and an extraordinary ability to stay focused at his work. A prodigious scientific writer, he had shown his capabilities in this field from an early stage of his career. His book on the FRCR examination preparation that he published when he was still in training, achieved a cult status and radiology trainees around the world used the book as their final step in getting prepared for the exams.

made the journey north to Newcastle to commence undergraduate training and culminated his preparation for consultancy with a year at the Mayo Clinic in Minnesota. At the age of 34, Richard was appointed Consultant in Trauma and Orthopaedics at North Tees Hospital in 1989 but moved to South Tees (firstly Middlesbrough General and later James Cook University Hospital) in 1991. He brought modern knee arthroscopic methods to the region initially and then went on to pioneer paediatric surgery. He was one of the first to adopt the Kurgan method of Ilizarov’s technique for limb reconstruction and non-union surgery. A fantastic teacher surgeon, his posteromedial release for CTEV was a masterclass in anatomical dissection. Always innovating, the Montgomery Hip Screw is a legacy of his attention to detail and desire to provide children with appropriate implants. Outside of the hospital he spent time as the Northeast RCSEd representative and spent time on the BOA Committee before committing his extracurricular activities fully to the RCSEd where he held office as Treasurer. Ever the teacher and mentor, he was also Chair of the FRCS Exams Committee. None of this was done for renumeration. He was a classic surgeon but a true doctor to his patients, trainees and colleagues. Lastly, Richard was an immensely devoted family man and was very proud of his children and grandchildren who he and Angie brought up to bring out the best in them. He will be a missed colleague teacher and friend, the true epitome of a ‘life well lived’. n

Asif’s skills in the field of scientific writing got only stronger when he started his job of a consultant radiologist at Stanmore. The workload that he faced provided him with rich pickings and he produced close to 400 scientific publications over the next 30 years or so. Most of these papers were published in the most respected scientific journals. He also wrote around ten radiology books (including his magnum opus on MR imaging of Musculoskeletal MRI) and co-authored many chapters in established textbooks. Asif was the senior member of the RNOH bone and soft tissue tumours service where his opinion was hugely respected. His national and international standing attracted a constant stream of case referrals that benefitted from his knowledge and expertise in making the correct call for management. Right until the end of his tragically short life, Asif remained hugely productive not just in scientific writings but also in his radiological examination reporting figures. Asif was a deeply religious and quiet person. However, he had a wry sense of humour which he regularly used to showcase in the weekly sarcoma meeting at Stanmore with a brilliant sense of timing. The hilarity of his comments sounding sharper to people who were not familiar with that side of his personality and would lighten the mood even in the most difficult of situations. Asif had a lot of time for his students. These ranged from radiology and orthopaedic surgical fellows to A-level students with aspirations to become medics. He would help the willing students in their scientific research projects as a capable and highly competent mentor. He was also always extremely helpful to all his colleagues in their daily workload. Asif was diagnosed with glioblastoma multiforme in March 2022. He succumbed to this cancer some 17 months later. He leaves behind his widow, four children, a large circle of friends and colleagues and hundreds of students spread around the world. His wisdom, knowledge, work ethic and dry humour will be sorely missed by all who knew him. n

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