Journal of Trauma & Orthopaedics – Vol 8 / Iss 1

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

A Surgical * Day Begins *From the editor p03

NOA – Improving quality in orthopaedic care p29

Improving the undergraduate T&O experience p32

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Journal of Trauma and Orthopaedics


In this issue...

3 5

From the Editor Bob Handley

35 Less than full time

From the President: Fresh faces and ideas Don McBride

6 Incoming BOTA President Tricia Campbell

8- 10 Latest News 12- 25 News 20 Should women do orthopaedics?

A topic explored at the Future Women of Orthopaedics event at St George’s University of London

24 Implementation of the new

T&O curriculum

26 The Musician’s Hand (and arm)

Ian Winspur

28 Reflections on life as a Regional Specialty Professional Advisor (RSPA) Rob Gregory

29 National Orthopaedic Alliance –

Improving quality in orthopaedic care

Peter Kay and Philip Turner

32 Improving the undergraduate Trauma

and Orthopaedic experience. Adoption of a modern teaching approach

Jamie A Nicholson, Gavin Brown and Hamish Simpson

training: Being a parent and an orthopaedic trainee

Anh T V Nguyen, Caroline B Hing and Alex Trompeter

Network – Collaboration, facilitation, empowerment


36 The Birmingham Orthopaedic

Usman Ahmed

38 Medico-Legal: What is consent?

John de Bono

orthopaedic trainees returning to training after taking time out of programme

40 Trainee Section: Supporting

Tricia Campbell

44 Subspecialty Section: Diversity:

Women in orthopaedic surgery – a perspective from the International Orthopaedic Diversity Alliance

Jennifer A Green, Vivian PC Chye, Laurie A Hiemstra, Li FelländerTsai, Ian Incoll, Kristy Weber, Margy Pohl, Carrie Kollias, Katre Maasalu, Magaly Iñiguez, Dafina Bytyqui, Margaret Fok, Philippe Liverneaux, Elham Hamdan, Violet Lupondo and Caroline B Hing

52 Subspecialty Section: Diversity and

inclusion in trauma and orthopaedics at the dawn of a new decade

Caroline B Hing, Giles Pattison, Robert Gregory, Fergal Monsell, Justine Clarke, Lisa Hadfield-Law and Deborah Eastwood

Women in orthopaedics: the trainee experience

56 Subspecialty Section:

Morgan Bailey, Zoe Little, Amy Garner, Roshana Mehdian and Liza Osagie

59 In Memoriam:

Alexander Benjamin, Charles David Richard Lightowler

60 Products, Courses and Events

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.

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. JTO | Volume 08 | Issue 01 | March 2020 | | 01


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

Credits JTO Editorial Team l l l l l

Bob Handley (Executive Editor) Rhidian Morgan-Jones (Editor) David Warwick (Medico-Legal Editor) Tricia Campbell (Trainee Section Editor) Caroline Hing (Guest Editor)

BOA Executive l Don McBride (President) l Phil Turner (Immediate Past President) l Bob Handley (Vice President) l John Skinner (Vice President Elect) (Honorary Treasurer) l Simon Hodkinson (Honorary Secretary) l Deborah Eastwood

BOA Elected Trustees l Don McBride (President) l Phil Turner (Immediate Past President) l Bob Handley (Vice President) l John Skinner (Vice President Elect) (Honorary Treasurer) l Simon Hodkinson (Honorary Secretary) l Deborah Eastwood

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

Policy and Programmes Director of Policy and Programmes

- Julia Trusler

Programmes and Committees Officer

- Harriet Wollaston

Educational Programmes Assistant

- Eliza Khalid

Communications and Operations Director of Communications and Operations

- Emma Storey

Interim Director of Communications and Marketing

- Annette Heninger

Marketing and Communications Officer

- Sabrina Nicholson

Membership and Governance Officer

- Natasha Wainwright

Online Examination Operations Project Manager

- May Elphinstone

Publications and Web Officer

- Nick Dunwell

l Colin Esler


l Peter Giannoudis

Director of Finance - Liz Fry

l Grey Giddins l Robert Gregory l Anthony Hui l Andrew Manktelow l Ian McNab

Deputy Finance Manager - Megan Gray Finance Assistant - Hayley Oliver

Events and Specialist Societies

l Fergal Monsell

Head of Events - Charlie Silva

l Rhidian Morgan-Jones

Events Administrator - Venease Morgan

l Hamish Simpson

Exhibitions and Sponsorship Coordinator

l Arthur Stephen l Duncan Tennent

- Emily Farman

UKSSB Executive Assistant - Henry Dodds


Copyright© 2020 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C


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

From the Editor... Bob Handley


ow go back and look at the front cover. Who is scrubbing up? Man or woman? If a man, did you presume them to be a surgeon or a nurse? If a woman, a surgeon or a nurse? Now look at ourselves; the T&O establishment does not exhibit great diversity. Currently the BOA has no women elected trustees (we believe there have only ever been three), the FRCS (T&O) has few women examiners, at the Congress in 2019 the number of ‘Manels’ (men only panels) was noted and criticised. Whilst there is change in our world of T&O practice, this is gradual. Much of this issue is themed to tie in with International Women’s Day, and to celebrate and champion female surgeons across the globe. We debated how to encourage readers to actually read the section on diversity, and in particular what to put on the front cover. A collage of women surgeons, whilst straightforward, would I feared (as a grey haired white male) appeal primarily to the converted. Whereas ‘the anonymous person scrubbing’ was placed front and centre to entice all of us to briefly consider our own assumptions and then perhaps, be persuaded to read the many relevant articles in this issue. We cannot control everything, but all of us can and should aim to play our part in creating an environment where medical students, juniors and consultants have no barriers, either real or perceived to a full career in T&O Surgery, apart from the need to demonstrate sufficient ability, aptitude and enthusiasm. However diverse the T&O workforce may be it will have to comes to terms with and negotiate a changing landscape. The changes for the requirements of a trainee are introduced in ‘Implementation of the new T&O curriculum’ (page 24). The article on the National Orthopaedic Alliance (page 29) gives background to an organisation of which we may have heard and indeed which affects us but of which most of us have little or no understanding. We are not just affected by our own parochial organisational changes but those to the law in general, John de Bono asks ‘What is consent?’, and so should we. Whilst this article relates primarily to elective practice the awkward issue of consent in non-elective work will be dealt with in a future issue.


The issue includes a letter to the editor on page 23, in this case relating to supracondylar fractures. We do not get many letters, I am hoping this is because they have not been encouraged rather than a lack of interest. However, with an online facility for the JTO we are in a position to publish a precis in the printed version and the full letter online; correspondence is now welcome.

BOA contact details

This issue of JTO and a significant component of the agenda outlined by Don McBride in his ‘From the President’ relates to diversity. How this is manifest in opportunities for women is often used as a barometer for diversity in general as this is readily measured. However, career progress based on ability, aptitude and enthusiasm should apply to all. n

Open Box M&C, Regent Court, 68 Caroline Street, Birmingham B3 1UG Email: | Telephone: +44 (0)121 200 7820

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

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

JTO | Volume 08 | Issue 01 | March 2020 | | 03



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From the President

Working together – the way forward Don McBride

Over the past 12 months we have been working hard on the implementation of our new strategy, underpinned by a new streamlined committee structure. We were delighted with the response to the committee recruitment in the autumn and have made good progress in ensuring representation from all areas of our Association (see page eight for a full list of appointments). Building on these foundations we now look to grow links with politicians, colleagues and associated groups to ensure our influencing and engagement work is focused and proactive.


t the time of writing, the Brexit bill has been passed and the final act is timed for 31st January. What is uncertain is the exact implications of the future health economy under a government with a convincing majority. The major concerns remain; NHS funding, potential independent care expansion, waiting times and fair and efficient pathways for accessing care. In addition, it is likely that there will still be some European influence on medicine and how it functions, for example, the Medical Device Regulations (MDR) coming in May 2020 and other aspects of European political change. I am sure that all will be aware that we shall be keeping close links with our European colleagues as will many other British societies irrespective of Brexit. Rest assured that the British Orthopaedic Association shall continue to engage with politicians when changes potentially affect our membership and the patients that we treat. Watch this space. The diversity of the Trauma and Orthopaedics workforce has been much debated over the past year, with Council and the Specialist Societies in agreement that this must be a priority issue. We are becoming, albeit some would say too slowly, a more diverse profession but there is still much to be done. One of the principle components of our theme for Congress shall be around Diversity and Inclusion, removing barriers and driving equity of access to a Trauma and Orthopaedic career. As many will be aware we already have a Working Group looking at these issues and an update is available elsewhere in this Journal entitled ‘Diversity and inclusion in Trauma and Orthopaedics at the dawn of a new decade’ by Caroline Hing et al, an excellent description of where we are now and where we need to be in the future. There are associated articles from the International Orthopaedic Diversity Alliance and a trainee perspective entitled ‘Women in Orthopaedics: the trainee

experience’ by Morgan Bailey et al. These are both enlightening and progressive. Clearly the position is not entirely restricted to the United Kingdom and there are excellent reviews available from the Australian, New Zealand and more recently Canadian Orthopaedic Association for those who wish further information and an International perspective. The future should be bright for all. In relation to our associated groups and societies we are continuing to work together with other medical, trauma and orthopaedic societies locally, nationally and internationally. We would particularly like to develop and enhance our links with World Orthopaedic Concern and our members who are currently involved in assisting low and middle income countries with education and training in our specialty. There are several good examples of similar associations, of special note the Australian Orthopaedic Association in the Asia-Pacific region, who have led and organised this process to the benefit of surgeons and, ultimately, patients across the globe. Updates on this process will be available in due course. Finally, we are all working hard towards Congress in September and I am pleased to announce that my Presidential Guest Speaker shall be Professor Noel Fitzpatrick and that the Howard Steel Lecture will be presented by Professor Ed Hawkins from the National Centre for Atmospheric Science, Department of Meteorology at the University of Reading. I look forward to seeing you all there. n

JTO | Volume 08 | Issue 01 | March 2020 | | 05


Incoming BOTA President – Tricia Campbell I am delighted to be elected as BOTA President for the forthcoming year. My BOTA journey started three years ago as BMA rep. During my tenure the contract re-negotiations were taking place. It is at this point that I realised how important it was for the orthopaedic voice to be heard. I then sat on the BOTA executive as secretary, it soon became apparent to me that BOTA had the potential to make significant positive changes to our training. I am an orthopaedic registrar in the North East, currently out of programme working as a Leadership and Management Fellow at Health Education England (HEE). In this role I have chaired the Trainee Executive Forum, quality assessed the Foundation Programme locally, sat on ARCP appeals panels and led on a national programme of work focused on improving the trainee experience and wellbeing. Medical education is an area that I am passionate about. I am currently working on my Masters dissertation which will explore the reasons for different attainment amongst surgical trainees. I love both motorsports and trauma, so I am often found at a racetrack. Croft, in Darlington, is my home circuit and I was lucky enough to work at the Formula 1 in Silverstone last summer. I am proud to say that this year we have the most diverse BOTA committee to date and I believe an exceptional group of motivated trainees with a passion to improve the trainee experience. I would like to thank you all for your enthusiasm, kindness and support, and look forward to working with you this year. n

“I am proud to say that this year we have the most diverse BOTA committee to date.”

BOA Instructional Course 2020 Kohila Vani Sigamoney


he 49th Annual BOA Instructional Course 2020 was held in Manchester at etc. venues on the 11th January 2020. It was an educational course that allowed trainees as well as SAS Surgeons to come together to share knowledge and also training ideas whether you plan to imminently sit the FRCS (Tr and Orth) examination or not. The course provided clinical updates and is important as part of Continuing Professional Development (CPD). There were 106 delegates and 36 faculty that attended the event. The venue itself was excellent with good facilities and was comfortable. Being in central Manchester, it was easy to get to. The regular breaks and refreshments helped us focus during lectures and group discussions, and the pace of the course was steady and not rushed. It goes without saying that the faculty were excellent. Two parallel streams provided clinical updates and case based discussion. The clinical updates were of seven subspecialties. Each delegate also attended four group sessions for case based discussions on bone tumours, complex regional pain syndrome (CRPS), limping child and cauda equina, the latter two being critical conditions for training purposes. We had the opportunity to get case based discussions (CBDs) completed for the group sessions. Due to the limited group size numbers, we each managed to get four CBDs signed off, which is more than some delegates expected. Overall, this was a very relevant and useful course and I would definitely recommend it to anyone interested in keeping up to date, improving confidence for the examination, and getting CBDs. n

06 | JTO | Volume 08 | Issue 01 | March 2020 |


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Latest News

Upcoming Fellowship Schemes The BOA offers several fellowship schemes for BOA members, three of which are due to launch for their 2020 round this spring. Members should check their emails and the BOA website for further information about this year’s: • Travelling Fellowships • Future Leaders Programme • Places on the FORTE summer school.

Committee appointments Following a successful round of applications, the BOA would like to congratulate all those who have been appointed onto the new BOA Committees: Orthopaedic Committee Mark Bowditch Nick Aresti Trauma Committee Alex Trompeter Mansoor Chaudhry Research Committee Chinmay Gupte Michael Whitehouse Medico-Legal Committee Shyam Kumar Simon Britten Education and Careers Committee Lead for Courses – Niall Eames Lead for Medical Students – Sarah Stapley Lead for Diversity – Caroline Hing SAS Rep – Anna Bennett

Training Orthopaedic Trainers (TOTs) Upcoming dates:

5th - 6th May 2020 (London) The TOTs course aims to improve the standard of teaching for those in trauma and orthopaedic (T&O) training and practice. The basic premise of the course is that if T&O trainers understand how people learn and how the T&O curriculum works, they can translate that understanding into action and improve their teaching. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. For any queries, please contact If you would like to sign up, please visit our website at

New Year’s Honours The BOA would like to congratulate the following members of the orthopaedic community who were awarded honours at the start of the year: • Prof Karen Barker, Professor of Physiotherapy and Clinical Director for Trauma and Orthopaedics at Oxford University Hospitals NHS Foundation Trust. (OBE) • Dr Sue Greenhalgh, Consultant Physiotherapist, Bolton NHS Foundation Trust. (OBE) • Dr David Alastair McDonald, National Lead for Enhanced Recovery, Scottish Government. (MBE) • Jane Pyman, Consultant Physiotherapist, Bristol. (MBE)

Medical Student Essay Prize Medical students are invited to submit an essay (no longer than 1,000 words) answering the following question: ‘Discuss your ideas on how the BOA can utilise social media and new forms of communication to improve engagement across the profession including students’. Submissions open on Wednesday 1st April 2020 and close Thursday 30th April 2020. For more information on the competition and to see our FAQs, please visit the BOA website

NICE Guideline on joint replacement (primary): hip, knee and shoulder Keep an eye out on the BOA website for the updated NICE guideline on joint replacement, which is due to be released in the spring.

08 | JTO | Volume 08 | Issue 01 | March 2020 |

Recent reports/publications of interest Readers may be interested in the following: • Fracture Liaison Service Database annual report, published January 2020 by HQIP. • Research priorities for the management of broken bones of the upper limb in people over 50 have been published at www. (This report was published as a result of a James Lind Alliance Priority Setting Partnership programme that was cofunded by the BOA). • Getting It Right in Orthopaedics follow-up report has been published by GIRFT. The report can be viewed at: orthopaedics-follow-up/.

Latest News

BOA Annual Congress 2019

15th - 18th September, ICC Birmingham

The theme for the 2020 Annual Congress is ‘Working Together’, collaborating and working in partnership to bring a number of revalidation sessions on specialist topics along with keynote lectures. This year we are pleased to have Professor Ed Hawkins, from the National Centre for Atmospheric Science delivering the ever popular Howard Steel Lecture and the renowned orthopaedic-neuro veterinary surgeon Professor Noel Fitzpatrick as our Presidential Guest lecture. We will also have an update from the BOA President, Don McBride on his presidential year. The scheduled revalidation sessions will cover a wide range of specialities including trauma, hips, spines, knees, foot and ankle to name a few along with Free papers being led by senior members of the BOA and Specialties Societies. The Friday of Congress is as always dedicated to our educational and training sessions for medical students and trainees. Anyone interested in exhibiting at Congress please contact the Events and Exhibition Coordinator, Emily Farman on

Registration BOA members can once again register at a discount of 100% for a limited time only during the Early Bird Registration period. Terms and conditions apply, please visit for details and further information. Early Bird registration will open Monday 20th April and closes on Saturday 7th June 2020. Full registration will open on Monday 8th June 2020.

ABSTRACTS NOW OPEN! BOA Annual Congress 2020 15th - 18th September ICC Birmingham

Dates for Abstract submissions : General Submission : 22 January - 15 April Medical Student Submission: 16th April - 29 May

Training Orthopaedic Educational Supervisors (TOES) Upcoming dates:

24th March 2020 (London) & 30th June 2020 (London) The new T&O curriculum will address concerns expressed by many Educational Supervisors about the over refined structure of ISCP: of tick boxes and forms. Our trainees need to learn professional judgement, insight, leadership, and the ability to work with others, alongside the operative skills required to be a safe surgeon. The new updated curriculum should help us do this more effectively. This one day course is designed to help Educational Supervisors make the changes, scheduled for October 2020, work for them and their trainees. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. For any queries, please contact If you would like to sign up, please visit our website at

JTO | Volume 08 | Issue 01 | March 2020 | | 09

Latest News

UKITE 2019 All programmes across UK and Ireland sat UKITE between 6th – 13th December 2019, as well as trainees from across South Africa on 17th – 18th January 2020. We are pleased to announce that in total 790 Trainees and SAS surgeons from the UK and Ireland sat the exam, an increase of 30 on the numbers who sat in 2018. The training programme that achieved the highest mean score (64%) was North West (Mersey). The average score across all participants was 54%. We would like to thank all those involved in the production and delivery of UKITE. For more information on sitting UKITE in 2020 or getting involved in UKITE, visit or email

First BOAST published in journal Injury The BOA is delighted to have established a new partnership with the Injury journal through which Trauma BOASTs will be published with an accompanying commentary. The first BOAST to be featured is ‘Open fractures’ which appears in the latest print edition and online. BOA members have access to the full article until mid-March at the following link:

James Lind Alliance PSP surveys There are two current James Lind Alliance Priority Setting Partnerships with surveys open. The BESS Elbow Conditions PSP survey can be found at: https:// elbowpsp and the survey for the Complex Fractures PSP can be found The BOA urges members and readers to complete these survey and share the links with patients also as their input is particularly encouraged.

Ian Paterson Inquiry publishes its findings


he inquiry into breast surgeon Ian Paterson published its findings shortly before this JTO went to press. A future issue of the Journal will provide further analysis of this report, and we provide here a short summary of the findings. The inquiry report, led by the former Bishop of Norwich, Rt Rev Graham James, begins as follows: “This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again.” The report has investigated events relating to Paterson’s practice at Solihull Hospital and two independent Spire hospitals from the late 1990s onwards. The first concerns about his practice were raised by a colleague in 2003, while further concerns were raised in 2007, but he was only stopped from practicing in 2011. In 2017, he was jailed for various counts of wounding with intent and unlawful wounding relating to 10 of his patients, with a total sentence of 20 years. Many more patients are believed to have been harmed by him.

10 | JTO | Volume 08 | Issue 01 | March 2020 |

The inquiry report is broad - covering NHS and independent sector, and the wider roles of regulators such as the Care Quality Commission and private medical insurance companies. In the opening remarks, the Rt Rev Graham James comments that, “There is no process, procedure or regulation which can prevent malpractice on its own. This report is primarily about poor behaviour and a culture of avoidance and denial.” It makes 15 recommendations for change, which include recommendations about: • improving treatment information and ensuring all patients have a letter explaining, in simple language, their condition and treatment; • ensuring a time period is provided for patients during the consent process to allow them time to reflect on their diagnosis and treatment options; • improvements in complaints processes and visibility of these processes for patients; • reforming the current regulation of indemnity products for healthcare professionals, in light of what the inquiry describes as “serious shortcomings” in the current system; • improved processes for investigating health professionals and alerting other hospitals in which they practice wherever there are perceived risks to patient safety. The full report is available online at:

34th EDINBURGH INTERNATIONAL TRAUMA SYMPOSIUM AND TRAUMA INSTRUCTIONAL COURSE 18th - 21st AUGUST 2020 Book early to secure viva and cadaveric breakout places. Early bird discount until 30th April 2020 TRAUMA SYMPOSIUM 19th-21st AUGUST 2020 Annual meeting for established orthopaedic surgeons with renowned international faculty including Heather Vallier, Michael Gardiner, Roger Van Riet and Jan-Erik Gertsen. Three day meeting focused on revalidation and update through a combination of short interactive lectures and case based discussions. Breakout sessions include cadaveric surgery focusing on surgical approaches and modern fixation techniques TRAUMA INSTRUCTIONAL COURSE 18th-21st AUGUST 2020 Four day orthopaedic trauma course suitable for established surgeons, trainees and AHPs Comprehensive lectures and case based discussions on the assessment and management of paediatric, adult and fragility fractures. Breakout sessions including cadaveric anatomy teaching and FRCS viva practice Venue: Sheraton Hotel and Edinburgh Medical School Visit us during one of the most exciting times of the year with the world famous Edinburgh International Festival and Fringe.

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BOA Chatterjee Travelling Fellowship Sara Dorman


he last year has been an eventful year, with both my husband and I sitting and passing the FRCS at the same time (despite all our friends, family and colleagues thinking we were mad), securing two international fellowships, battling family illness and relocating our family temporarily to Cambodia after I received a BOA travelling fellowship. I have spent the last six months at the children’s surgical centre in Cambodia, where I have undertaken both a clinical and training role. I have implemented a paediatric orthopaedic curriculum and an AO style practical course in basic fracture management for the rotating residents, which will continue to roll on a six monthly basis once I leave, using the digital resources supplied. In Cambodia there are very little elective paediatric services; there is no screening for DDH and very late diagnosis is

the norm. I spent a lot of time raising awareness and training local staff in screening for DDH, principles of practical management of DDH and training in western procedures for paediatric surgeons including femoral and pelvic osteotomies. In addition to this work, I have educated the Khmer surgeons to recognise and treat paediatric conditions such as congenital vertical talus and congenital pseudoarthrosis of the tibia – last month we did the first periosteal grafting and Paley X type procedure in Cambodia. Cambodia’s main mode of transport is the motorbike and, due to a paying healthcare system and high levels of poverty, many who come off their motorbikes seek traditional medicine or no care at all. The Khmer surgeons here see and successfully treat very high volumes of infected non-

unions, plexus and peripheral nerve/plexus injuries. Similarly, obstetric and paediatric care is difficult to access and of variable quality resulting in a spectrum of cerebral palsy type cases either at birth or post meningitis. I have been able to expand my personal cross speciality experience in nerve injury and tendon transfer in brachial plexus injury, microsurgery, selective denervation for spasticity and congenital hand. This experience has been both life and career changing and I am extremely grateful to the BOA and the Chatterjee fellowship. I would thoroughly encourage anyone considering overseas work to take a leap of faith – it will be a rewarding decision! n

British Trauma Society Meeting Review

Ansar Mahmood


he British Trauma Society had its Annual Scientific Meeting in Nottingham from 5th – 7th November 2019. Keynotes speakers came from a very diverse expert faculty showcasing the multi-disciplinary nature of major trauma in the real world. This included stellar talks on the current concepts and state of trauma research from Professor Karim Brohi and Professor Matt Costa on why UK trauma research is currently leading the world in our output and some key practice papers shaping practice. The keynotes included: • Professor Ian Hutchinson of Saving Faces fame and a renowned maxillofacial surgeon covering the evolution and history of trauma in this relatively new specialty. • General surgeon Mr Adam Brooks from the busiest level one centre in the UK on why we are good but not as good as we think we are in managing exsanguinating trauma. • Plastic surgeon, Mr Anton Fries presented on the current concepts on soft tissue management in major trauma. • Emergency medicine was represented by Dr Chris Turner covering why ‘Civility Saves Lives’ which has rightly gathered enormous traction nationally and internationally. • Major trauma rehabilitation update from a military perspective by Grp Captain Alexander Bennett. • Thoracic Surgery ‘state of the nation’ trauma update on chest wall injury by John Edwards.

Prizes were awarded and trainees presented their original research in poster and podium format. We had a significant increase on recent years abstract submissions with almost 200 applicants. There was an oversubscribed preconference Ex-Fix workshop expertly chaired by Professor Ian Pallister. n

12 | JTO | Volume 08 | Issue 01 | March 2020 |

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BOFAS Annual Scientific Meeting: Nottingham, November 2019


his year celebrated the 44th Annual Meeting of the British Orthopaedic Foot and Ankle Society in Nottingham where the meeting was organised by the President Miss Patricia Allen. There were 560 delegates in attendance. We continue to modify the format annually to maintain interest and diversity. There were five instructional sessions during the three-day meeting: the management of the diabetic foot; research and outcomes in foot and ankle surgery; ‘rare and regular - what to do’; metabolic conditions affecting the foot and ankle, and the management of ankle arthritis. These generated interesting debate. We included four keynote lectures: ‘The control of infection in diabetic foot disease’ delivered by Dr Deborah Modha, Consultant microbiologist; ‘Complex Regional Pain Syndrome’ delivered by Professor Roger Atkins; ‘Vitamin D in Orthopaedics’

James Davis

by Professor Bill Ribbans and ‘Are we being duped by evidence-based medicine’ by Mr Jeremy Field. There were 23 free papers delivered throughout the meeting on a variety of interesting topics with the winner of the Klenerman podium presentation prize Mr D McCormack with a paper entitled, ‘The deep deltoid ligament and stability after ankle fracture: a cadaveric study’. The second day morning session was split, the allied health professionals focussed this year on the forefoot and its disorders. In the main auditorium there was a session on setting up local hub and spoke networks. At lunchtime we ran the third fellows’ forum where the role of fellowships and the early challenges of a consultant’s career were discussed. The meeting concluded with the handover of the presidency from Miss Patricia Allen to Mr James Davis who announced that the 2020 meeting will be held in Torquay from 4th - 6th November. As always the meeting was seamlessly organised and we would like to thank our secretariat, notably Miss Jo Millard, who resolved all issues effectively and efficiently and continues to keep the heart of our society beating. n

BOTA Educational Congress 2019 George Holland


his year’s Educational congress took place 27th – 29th November 2019 at the Royal College of Surgeons Edinburgh. We welcomed 329 registered delegates over three days to the historic venue. For the third year in a row registration was offered free of charge to all who attended. Once again, the event sold out ahead of schedule and an excellent programme over a variety of topics was delivered thanks to our wonderful faculty. Special thanks go to the Orthopaedic Trauma Society (OTS) who return year after year to deliver a half day of high-quality trauma-based teaching. This year’s topic was upper limb and a master class was delivered in evidence-based management of common upper limb injuries. AO spine delivered their excellent half day course focussing on the future of spinal surgery and practical workshops for

14 | JTO | Volume 08 | Issue 01 | March 2020 |

registered delegates. We also had fantastic half day workshops from the British Society for Surgery of the Hand (BSSH) and the British Orthopaedic Foot and Ankle Society (BOFAS) who delivered lectures on key topics for day to day practice and FRCS exams. We were also able to offer content for our junior BOTA members delivering a half day of workshops especially for medical students and junior grades interested in a career in orthopaedics. These sessions included key tips for being successful in registrar interview. Our Post-FRCS members also had a day of lectures and talks from newly

appointed consultants on how best to manage admin time and tips for the new consultant. Finally a special thank you for all our industry sponsors who allowed us to be cost neutral and deliver congress free to all. Without them none of this would be possible and we are sincerely grateful for all their ongoing support. The following awards were awarded during congress 2019: Trainer of the Year (TOTY) - Ms Sally Hobson (Hull Royal Infirmary, Yorkshire deanery) Training Program Director of the year (TPDOTY) - Mr Ben Ollivere (Nottingham University Hospital) Research podium presentations - Bence Baljer – ‘Resorbable composite materials for fracture fixation’ n


Meeting Review - SICOT 2019 Phil Turner


he 40th meeting of the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) was held in Muscat, Oman from the 4th - 7th December at the Oman Convention and Exhibition Centre. SICOT was founded 90 years ago with the aim of being a truly international association promoting the advancement of orthopaedics and traumatology through teaching, research and education. The breadth of content was outstanding with a combination of scientific and instructional sessions, keynote and plenary speakers, cadaveric and dry labs. The 9th SICOT Education Day, 31st International Course on Polytrauma Management and the 17th SICOT Diploma Examination were all incorporated into the programme. In addition, there were parallel sessions organised by partner societies including World Orthopaedic Concern. The congress centre was superb, combining beautiful architecture, excellent facilities and a convenient location for the airport and surrounding hotels. Almost 2,300 participants attended from more than 80 countries. For the third year, the scientific programme was put together by Vikas Khanduja from Cambridge. It is a testament to his enthusiasm and organisational skills that the meeting ran so smoothly with more than ten sessions running at any one time. The item that sticks in my memory was the remarkable opening ceremony. It was full of energy and highly entertaining with a focus on the history, art, culture and music of Oman. Perhaps something to think about for our own Congress? n

British Scoliosis Society (BSS) 2019 Meeting Review


Sashin Ahuja

ardiff City Hall had the privilege of hosting the 43th Chapter of the BSS from 21st – 22nd November 2019. The programme was packed with stimulating intellectual delights with keynote lectures given by opinion leaders from America, Denmark and nationally covering current topics such as vertebral body tethering and adult spinal deformity amongst others. The number of good quality abstracts seems to be increasing year on year and we surpassed the number of abstracts submitted compared to recent meetings. The prestigious Greg Haughton lecture was delivered by Mr Ian Nelson from Bristol. Given the recent press about spinal implants, it was our pleasure to have Mr Richard Parkinson, who on behalf of Orthopaedic Data Evaluation Panel (ODEP) and Beyond Compliance, gave an update on device surveillance and the introduction of new implants which we as a spine fraternity are going to embark on. Like our day to day work, the BSS platform gave us an opportunity for multidisciplinary working and interaction with our anaesthetic colleagues (National Paediatric Spinal Anaesthetic Network-NPSAN), neuromonitoring colleagues (Neuromonitoring UK-NMUK) and our allied health professional (AHP’s). The three allied organisations had a parallel meeting to the BSS. This platform helped us to have joint sessions with the allied organisations to discuss, debate and generate standards of care guidance in managing difficult scenarios in our practices such as, postoperative care of patients following surgery for adolescent idiopathic surgery i.e. HDU or high care on the ward, and managing neuromonitoring alerts in scoliosis surgery. The charity supported at the meeting was Horatio’s Garden in support of the garden being built by the charity at the newly relocated Spinal Cord Injury centre in Cardiff. The meeting was very well received and we all look forward to meeting up again at the next BSS meeting which will be held in Edinburgh during November 2020. n

16 | JTO | Volume 08 | Issue 01 | March 2020 |

Annual Conference Saturday 6th June 2020 CHESTER RACECOURSE

• Hear about current WOCUK projects and how to get involved • Exciting guest speakers • CPD Points Members: £45 Non-members:£55

Please register online via Eventbrite Link

Abstract Submission NOW OPEN We welcome the submission of topical papers in the field of Orthopaedics in the Low and Middle-Income setting for Podium Presentation

Abstract Deadline 30th April 2020 Submit entries to: @orthoconcern


Review of the IACES Madrid Elbow Course May 2019

Nashat Siddiqui

The elbow is a somewhat unloved joint. It is shared between hand surgeons and shoulder surgeons and usually receives some attention during hand surgery and shoulder surgery conferences but rarely has a whole course devoted to it. So with this in mind I travelled to Madrid to attend the International Advanced Course on Elbow Surgery (IACES), also known as the Madrid Elbow Course, which is held every two years. It was spread across three days with a packed agenda. Compared to the previous Madrid Elbow Course, this year was much bigger, with around 300 surgeons attending from around the world. There was a good mix of hand and shoulder surgeons, along with a few surgeons whose main practice is the elbow. There was also a good turnout from senior trainees/ fellows, but unfortunately not as many physiotherapists. 18 | JTO | Volume 08 | Issue 01 | March 2020 |

It was convened by Samuel Antuna, Raul Barca and Joaquin SanchezSotelo, all of whom are accomplished upper limb surgeons. There was an excellent international faculty. The UK was represented by Amjid Ali and Adam Watts, and other accomplished speakers included Buddy Savoie and Mike McKee from the USA, Graham King from Canada, and prominent elbow surgeons from Europe including Roger van Riet, Denise Eygendaal, and Alberto Schneeberger. The content was very varied, ranging from tennis elbow to elbow arthroplasty. I found this very useful as a refresher, as well as learning new developments in the past two years, such as an increasing trend away from using steroid injections to treat tennis elbow. The course was delivered as a series of lectures rather than short free paper presentations. This was good because it allowed the speakers to impart their wisdom as well as quoting recently published literature. Each lecture was of an appropriate length to keep the audience

engaged, as the days were very long. Inevitably the broad range of topics meant some subjects were not covered in as much detail as I had hoped, but there was usually enough time at the end of each group of lectures to ask the faculty questions. It also generated a lively debate between the panel members if a controversial topic was raised. Additionally, there were several live cadaveric surgery sessions, which were held at the hotel venue. This allowed the speakers to deliver lectures and demonstrate surgery without a significant delay between sessions. As expected for an international meeting the main language was English, and the venue staff also had excellent English. I thought it was very well organised, with good support from the conference organisers. There was also an app which proved very useful looking up lecture times, details of the speakers, maps of the venue etc. It was held at a large hotel in the business district which is a little distant from the city centre, but easily served by the Metro train system. There were the usual exhibitors but it was good to see they had brought their elbow products which often don’t get exhibited at hand or shoulder conferences. Madrid in May is a very good time to visit, nice and sunny but not too hot, and this was an added bonus to the meeting being held there – and of course lots of paella and churros to get into the Spanish spirit of things, if only there was time for a siesta too... n


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Should women do orthopaedics? A topic explored at the Future Women of Orthopaedics event at St George’s University of London Anh T V Nguyen, May Al-Shawk, Scarlett McNally, Caroline B Hing


think women should not do orthopaedics. You see a few around now, but it is just not the kind of job for a woman!”. There it was, said to me by an amicable male colleague at an after-work drinks event, an example of gender bias laid out in the open in a conversational, as-a-matter-of-fact manner. Another five colleagues at the same table all heard it, no one spoke a word. The silence was deafening. I asked myself, “Is that what they all think?”. It may well be. Previous surveys have identified a wide-spread perception that orthopaedic surgery is an ‘old boys’ club’ of physically heavily built macho rugby playing males1,2. This stereotype creates a lack of visible female role models, misconceptions about orthopaedic surgeon attributes and perpetuates the implicit nature of the discrimination reported by women in

20 | JTO | Volume 08 | Issue 01 | March 2020 |

surgery3,4. In combination with the family unfriendly hours, these barriers are said to underlie the gender gap in the orthopaedic surgeon workforce1,2,5. Since 1996, in the UK women have outnumbered men being 53 to 61% of medical school entrants6, 30 years later in 2019, only 6.7% of orthopaedic surgeons are women7. Against all odds, women orthopaedic surgeons appear to be fulfilled with their career choice8. It appears that this fact needs to be communicated to the junior doctors and medical students so that orthopaedics can attract applicants from our increasing female talent pool4,9. Motivated by this purpose, I launched into setting up an event at St George’s University of London to encourage medical students and junior doctors to consider a career in orthopaedics, entitled ‘Future Women in Orthopaedic Surgery’ on the 25th November 2019. It was

advertised via posters at St George’s University Hospitals NHS Foundation Trust (SGH) and online via the British Orthopaedic Association and Royal College of Surgeons of England communication platforms in order to attract attendees. The event had a great attendance (62 medical students, junior doctors and five industry representatives) attracting people from across the country. During the evening there was a varied selection of speakers to address a variety of relevant topics for the audience. Miss Caroline Hing, Consultant Orthopaedic Surgeon at SGH spoke eloquently about her career, with a healthy dose of humour and personal anecdotes. She corrected a few misconceptions, including women not being physically strong enough to handle the physical demand of orthopaedics, with an interactive demonstration of two petite female students successfully cutting a big stainless-steel bolt. Similarly, we discussed findings from a recent study that outlined the difficulties that many women face in the operating theatre due to surgical instruments not fitting their small hand grip10. A representative from a surgical instrument manufacturer, Stryker Corporation, reports that the company is incorporating ergonomic principles into their design of orthopaedic tools to fit various hand grips, making orthopaedic operations more technically efficient for women. Following from Miss Hing’s talk was a moving speech by Miss Swee Chai Ang, the

“Since 1996, in the UK women have outnumbered men being 53 to 61% of medical school entrants, 30 years later in 2019, only 6.7% of orthopaedic surgeons are women.”


first female Orthopaedic Consultant appointed to the Royal London Hospital in 1994. She talked about feeling that it was a responsibility to pursue her passion in orthopaedics and use her surgical skills as a gift in a noble profession in which patients put their complete trust in the surgeon’s hands, whether in London or in refugee camps in Gaza and Lebanon. For that gift, she persevered and persisted despite the prevalent discouraging opinions of others. She answered the question of “How one can become an orthopaedic surgeon?” with a few simple but profound words, “By being a human being, being a doctor, being a surgeon and being yourself”. The next talk was by Mrs Scarlett McNally, Consultant Orthopaedic Surgeon and Council member at the Royal College of Surgeons of England. In this talk she emphasised that one could operate while pregnant or breastfeeding and that it is more possible now than before to achieve a work-life balance in orthopaedics. This is partly due to a change in the practice of surgery with night operating now being reserved only for life- or limb-threatening cases, prompted by findings from the National CEPOD report in 199711. Following from her talk, Mr Simon Fleming, a London orthopaedic trainee, captivated the audience with his authentic talk about the importance of combating bullying, undermining and harassment

in the health care environment. He gave several examples about how bullying behavior could negatively affect both women and men. With Simon the audience explored the possible reasons underlying bullying behavior in the health care environment and the remedies to such behaviour, for example the ’Vanderbilt cup of coffee’ and chat initiative12.

Our last speaker, Mr Alex Trompeter, Training Programme Director for Orthopaedic Surgery for the South West London region, outlined the processes for Less Than Full Time Training for any gender and returning to work after a break such as maternity leave. After the talks, Miss Shamim Umarji, Consultant Orthopaedic Surgeon and Clinical Director for surgery at SGH led an engaging panel discussion with questions from the audience and more insights from the speakers. The evening concluded by a networking session alongside a practical session for attendees to try performing external fixation and femoral nailing skills on plastic bones. The event was a success. A post event questionnaire collected data from 42 attendees with 93% reporting that the event provided effective solutions regarding how to break down personal barriers to pursuing orthopaedics; 95% felt the event provided them with some aspiration towards selecting orthopaedics as a career, all would like to be invited to the next event hosted by the same organisers. Following these results, we plan to host a similar event in 2020. If anyone is interested, please contact Miss Anh Nguyen, Orthopaedic Registrar via email: anh.nguyen1903@ n


References can be found online at: publications/JTO. JTO | Volume 08 | Issue 01 | March 2020 | | 21


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

CAOS (Computer Assisted Orthopaedic Surgery (International))


BESS (British Elbow and Shoulder Society)

BASK (British Association for Surgery of the Knee)

BIOS (British Indian Orthopaedic Society)

BLRS (British Limb Reconstruction Society)

BORS (British Orthopaedic Research Society) 19-20 March 2020, Manchester 1-3 April 2020, Glasgow 10-13 June 2020, Brest – France 24-26 June 2020, Brighton 16-17 April 2020, Oxford 23-24 April 2020, Manchester 10-11 July 2020, Cardiff 7-8 September 2020, Bath

BSSH (British Society for Surgery of the Hand) 30 April - 1 May 2020, London

BOOS (British Orthopaedic Oncology Society) 5 June 2020, London

WOC (World Orthopaedic Concern) 6 June 2020, Chester

BOA Congress 2020, ICC Birmingham

BOA (British Orthopaedic Association) 15-18 September 2020, Birmingham

BOFAS (British Orthopaedic Foot and Ankle Society) 4-6 November 2020, Torquay EFORT 2020, The Messe Wien Exhibition & Congress Center

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) 10-12 June 2020, Vienna

22 | JTO | Volume 08 | Issue 01 | March 2020 |

BTS (British Trauma Society) 10-11 November 2020, Oxford

BSS (British Scoliosis Society) 26-27 November 2020, Edinburgh


Letter to the Editor Dear Sir, Re: Operations I no longer do… Open reduction of supracondylar fractures, by Fergus Monsell. JTO, Volume 07, Issue 04, December 2019, pps 30-31. I completely agree with Mr Monsell’s article, above, that is a breath of fresh air. I am of a generation of Orthopaedic Surgeons before Mr Monsell. Open Reduction of supracondylar fractures is an operation that I have never found the need to perform. I too have observed the remarkable remodelling that occurs during the years after the conservative treatment of such fractures. I have always treated these fractures conservatively, using the method described by Charnley1. I have since witnessed the widespread practice of the open reduction of supracondylar fractures, that is to my mind unnecessary, unless there is vascular involvement. From my personal experience, I also do not think that the use of a plaster cast is necessary. I sustained a left supracondylar fracture at the age of seven years. This was treated conservatively by manipulation under general anaesthesia and managed without a plaster cast. The arm was kept by my side under a shirt, together with a collar and cuff that allowed gentle early movement of the elbow, as the pain and swelling decreased. My left arm has functioned normally ever since.

The author, aged 7 years, one week after MUA of left Supracondylar Fracture

Left arm under shirt, supported with a collar and cuff, elbow flexed to 120°

Yours sincerely,


Richard Brueton MA MD FRCS Honorary Consultant Orthopaedic Surgeon

1. The Closed Treatment of Common Fractures. Chapter VII, 3rd Edition (1963). Charnley J. E and S Livingstone Ltd.

Submit your abstract!

39th Annual Meeting of the European Bone and Joint Infection Society

SAVE THE DATE 10 - 12 September 2020 Ljubljana, Slovenia

Main topics ]

Optimising antibiotic treatment of bone & joint infections


Optimal bone infection sampling and microbiological processing


Low-grade PJI – what is the best approach?


Musculoskeletal infections in children


Infections of arthroscopic implants, osteotomies and tendon reconstructions


Chronic osteomyelitis with good function. To treat or to live with?


Spinal infections


Fracture-related infections

Important dates

Abstract Submission Deadline: 10 April 2020 Early Registration Deadline: 1 July 2020

JTO | Volume 08 | Issue 01 | March 2020 | | 23


Implementation of the new T&O curriculum Rob Gregory


rom August to October 2020, T&O training will need to comply with the new curriculum. This will be generally available following approval by the GMC which is expected in the near future. Changes are necessary in order to comply with the GMC new curriculum standards that focus on the generic skills required to be a safe, effective consultant. They incorporate an improved appreciation about the ways in which trainees learn, accommodate changes in the way in which care is delivered, incorporate the interim changes introduced annually up to 2018 and ensure that the end product of training is a consultant with a broad range of experience, able to independently manage an unselected emergency case-load but also able to develop a subspecialty interest. Whilst new iterations are inevitably accompanied by heightened levels of anxiety, it is important to recognise that most of the practical aspects of the curriculum remain unchanged, there are no significant changes to the syllabus and the subject of the assessments remains broadly unchanged, with only the method of assessment being significantly altered. The three key elements with which trainers and trainees will need to become familiar are the Multiple Consultant Reports (MCR), the Generic

Professional Capabilities (GPCs) and the Capabilities in Practice (CiPs). For those unfamiliar with these elements, and for those wishing to learn more, there is an excellent overview, Surgical Curriculum 2020, that can be accessed from the ISCP homepage. This also gives trainers the opportunity to undertake a ‘mock’ MCR and is strongly recommended. Considerable support will be given to trainees and trainers in the lead up to the autumn but at trust level a decision will have to be made in advance about how the two MCRs required at the middle and end of a six-month attachment will be compiled, there being no didactic rules about this. A common method is likely to be a meeting at which members of the clinical team, not just consultant trainers, discuss the progress of all of their trainees, identifying areas of strength and areas where improvement is required. The conclusion of the meeting will be a recommendation specific to each trainee designed to meet their individual needs. For each Programme the introduction of the new curriculum will be co-ordinated by the TPD, and again Programmes are likely to vary in how this changeover will take place. Many will wish to incorporate into a training faculty meeting, advice and guidance about the changes and how they should

be implemented. TPDs in turn will be supported by the SAC and a meeting is scheduled for the evening of 2nd April, during the national selection process in Leeds, to discuss the curriculum implementation. An inevitable query will relate to transition to the new curriculum for senior trainees. It has been normal practice recently for there to be a transition period, with senior trainees having the option of staying with previous JCST guidance, for example relating to old Critical Condition CBDs. Whilst this transition period will also apply to the new curriculum, as it is predominantly the method of assessment rather than the subject of the assessment that is changing, it is hoped that Programmes will encourage all trainees to move to the new curriculum in the autumn, thus removing the inevitable frustration felt by trainers when having to use two systems in parallel. The introduction of the new curriculum may seem daunting but with advanced planning and with increasing familiarity with the process, it is likely that the transition will be smoother than feared, and trainees will rapidly begin to benefit. Certainly, the 500 trainees and trainers who have been introduced to the new curriculum over the last year consider it to be a significant improvement.

The BOA’s courses for trainers and educational supervisors (TOTs and TOES) have been fully updated to reflect changes to the new curriculum – for more information and to book onto a course visit or, or if you are a TPD interested in running TOES in your local area contact 24 | JTO | Volume 08 | Issue 01 | March 2020 |


Joint Action Challenge Events We would like to wish all of our runners, who are taking part in the Virgin Money London Marathon on Sunday 26th April, on behalf of Joint Action the best of luck. If you would like to support our runners please donate at We do still have places available for the British 10K (Sunday 5th July) and the Prudential RideLondon-Surrey (Sunday 16th August). If you’d like to get involved and help raise much needed funds for orthopaedic research, please visit the BOA website or email

Joint Action Christmas Appeal 2019 We would like to thank every single person that donated to the Joint Action Christmas Appeal which closed on Friday 28th February, with your help we raised over £8,000 for Joint Action, the Orthopaedic Research Appeal of the BOA. Your generous donations have helped the BOA Orthopaedic Surgery Research Centre (BOSRC) to continue developing important research projects throughout the year. Since forming in 2014, BOSRC has secured now over £11 million in external funding for nine new clinical trials! The BOA is also, for the first time, sponsoring ‘Surgical Specialty Leads’ for trauma and orthopaedics. They will work collaboratively with the BOA, our funded clinical trials unit and with other stakeholders to make progress in supporting development of research and trials. You can read more about the ways we are contributing to trauma and orthopaedic research on the BOA website at

Tissue and Eye Services, products we can supply • • • • •

Ground bone Femoral head DBM paste, putty, powder, sponge Femoral wedge A wide range of other allografts

Contact us, or visit our website to see the full product range Tel 0845 607 6820 Visit JTO | Volume 08 | Issue 01 | March 2020 | | 25


The Musician’s Hand (and arm) Ian Winspur

Extrapolating from US data, there are approximately 50,000 professional musicians in Britain and, of course, many more amateurs. They drive cars, play sports, indulge in DIY and cook and, unfortunately, are injured in such activities. It is with these injuries, coincidental to music, that orthopaedic surgeons are likely to find themselves treating musicians. In such circumstances, initial contact can be fraught.


Ian Winspur is a hand surgeon who, working initially in the USA, has for many years been treating injuries and chronic problems in the upper limbs of professional musicians enabling most to continue performing at very high levels. He is a trustee of the British Association for Performing Arts Medicine and an Honorary Lecturer at University College London.

he musician, fearing the possible end to their treasured playing and professional career, will be anxious, even agitated, desperately trying to convey to the surgeon the musical details – the instrument and the exact mechanical needs – often using musical terms. The surgeon, knowing the basic injury and repair and reconstruction required and not understanding the language, will often disregard or dismiss the musician’s comments, which is an error. Trust will be lost and, importantly, vital information regarding the musical positioning required, the contact areas and the reconstructive and rehabilitation goals will be missed. Mistakes will be made.

Fractures In striving for anatomical reduction, one may render a stable situation unstable and have to resort to open reduction, when otherwise not indicated, particularly in trying to secure early musical rehabilitation. When one might anticipate satisfactory healing and function with a degree of malunion in the non-musician, such malunions can cause major difficulties in certain musicians and clear examples exist. I recall a number of pianists with malunited clavicular fractures having difficulties with the anterior shoulder carriage and in two cases, the development of distal neurological loss due to pressure on the cords of the brachial plexus in association with the malunion. This could only be reversed by corrective osteotomy. Pronation in both arms in keyboard players and hypersupination and flexion in the left wrist of string players, are essential and if there is risk of compromise to these essential movements from fractures of the radial head, forearm bones or wrist involving the DRUJ, extra effort including open reduction when not otherwise indicated, has to be considered in the light of that musician’s specific needs. Open reduction of wrist fractures may also be performed more readily when the musical position, be it extreme flexion, may be compromised in malunion. Metacarpal fractures with only 5-10 degrees of rotation will be sufficient to prevent accurate fingering on string instruments and should be openly reduced when otherwise not indicated.

“Young guitarists are susceptible to median nerve irritation playing the instrument with too much wrist flexion. They need a guitar teacher to correct this error and their symptoms will disappear.”

Any surgical intervention must be pre-planned to prevent additional injuries to critical areas. The established goals in treatment are: • The exact location of the incisions. • Anatomic repair and reconstruction. • Adjustment of any anticipated loss of motion to that musician’s specific musical need. • A need for an early return to limited playing.

26 | JTO | Volume 08 | Issue 01 | March 2020 |

Applying these principles to fractures, tendon and nerve injuries may require modifications to surgical indications and some modification of technique from the standard surgical approaches.


Tendon and nerve injuries Tendon injuries need to be treated in the standard fashion but care needs to be taken in the location of incisions. When a tendon function is re-duplicated (examples would be an isolated profundus laceration with an intact sublimis or the extensor tendons at the base of the thumb) in a musician, the divided tendon must be repaired even if complicated and requiring free tendon grafting. The subtle loss even of a re-duplicated function, can be enough to imbalance and interfere with playing at the highest levels. The highest chance of recovery of useful sensation in nerve injury is by primary nerve repair and the loss of sensation in ‘non-critical areas’ can impact and unbalance the musician’s digit to seriously interfere with playing. ‘Less important’ sensory nerve, such as the terminal branches of the superficial radial nerve and the ulnar digital nerves should be repaired. Any digital nerve should be repaired up to the level of the DIP joint. Musicians also suffer from painful and degenerative conditions which afflict the general public - carpal tunnel syndrome, ganglions, trigger fingers, to name a few.

However, in my experience, surprisingly these conditions are less common than in the general public. This calls into question the role of repetition in the development of these conditions and the non-scientific belief that repetition causes injury. The management of these common conditions in musicians is generally conservative - ganglions should be aspirated, trigger fingers and areas of tendonitis should be judiciously injected with steroids and the initial approach to musicians with carpal tunnel-like symptoms should be conservative. If a musician has carpal tunnel-like symptoms but normal nerve conduction tests, surgery should not be performed. Young guitarists are susceptible to median nerve irritation playing the instrument with too much wrist flexion. They need a guitar teacher to correct this error and their symptoms will disappear. Young pianists and violinists, at times of prolonged and pressured playing, may develop carpal tunnel-like symptoms. They will also have the characteristic signs of wrist flexor tenosynovitis. Their nerve conduction tests will be normal. They will respond well to steroid injection into the carpal tunnel (avoiding injection directly into

the median nerve). They will fare very poorly from surgical release. Older musicians may develop classical carpal tunnel syndrome. Their nerve conduction tests will be positive. Steroid injection should still be tried initially but they may require surgical release and will respond well. Musicians can and do develop generalised and non-specific pain and aching in their arms and wrists related to tiredness, poor posture, poor technique, a mismatch with their instrument, tension when playing and excessive continuous practice. These are complex problems and need professional analysis. The first step however is to recommend a reduction in playing and not cessation of playing. Help needs to be sought from a trusted music teacher and therapist. The fundamental lesson however for the surgeon in dealing with the musician is to listen to what the musician is trying to explain, understand the specific mechanical musical requirements and the contact areas for that musician and plan before the scalpel touches the skin, so as not to cause additional injury. In simple terms, look and listen before you leap. n

The Musician’s Hand - A Clinical Guide: 2nd Edition Book Review by David Warwick Author: Ian Winspur

ISBN: 9783132410756

Date published: 2018 JP Medical Ltd, London ISBN: 9781909836815

Ian Winspur has been the UK’s leading expert on the musician’s hand for very many years. He has unparalleled wisdom and knowledge which he has imparted in his wonderful new book - The Musician’s Hand - A Clinical Guide. Musicians place inordinate demands on themselves and their hands; most instruments were never designed with ergonomics in mind. So it is hardly surprising that they are prone to upper limb problems. And moreover, minor ailments or injuries that would hardly affect most people can be career threatening for a musician for whom fine tolerances and huge stamina are essential. This book delves into not only the pathology but also the psychology of the musician, the ergonomics of many instruments and the nuances of treatment that has to be so carefully personalised. I would encourage anyone interested in music or the hand to get a copy of this beautifully presented book.

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Reflections on life as a Regional Specialty Professional Advisor (RSPA) Rob Gregory

If one word was to sum up the value of the Regional Specialty Professional Advisor, it would be communication. As I reflect on the last seven years in the role as RSPA for T&O in the Northern Region, I appreciate that as a valuable conduit for information dissemination from the College and Specialty Associations to the grass roots and vice versa, the RSPA is ideally placed.


Rob Gregory is a Consultant and Lead Clinician in Trauma and Orthopaedics at County Durham and the Darlington NHS Trust. Robert has an interest in surgical education and is currently chair of the specialist training committee for T&O. He is quality management lead in the School of Surgery in the Northern Deanery, an examiner at MRCS level and also a Regional Specialty College Adviser in T&O.

he evolution and implementation of commissioning rules is a perfect example. Given the current financial constraints within the NHS, there are few greater threats to our ability to maintain our high service standards, but at the same time commissioning changes offer us an opportunity that can be exploited. We have a platform that allows us to both emphasise areas of excellence in our practice, for example relating to the changes in arthroplasty practice that have emerged as a result of the National Joint Registry, and to shape service delivery based on high quality evidence, for example relating to the management of major trauma. The RSPA is perfectly positioned to facilitate both and is therefore a key member within our professional structure. So, who should consider applying for this role? Some experience as a consultant is clearly needed but there is no reason why the RSPA should be nearing the end of his or her career. Some experience in trust management is helpful, as is involvement

with training, but a desire to improve standards and an ability to both collect and disseminate information from and to the College and Specialty Associations and regional colleagues is perhaps the most vital. Of course, there are frustrations. An important role of the RSPA should be to help assure the quality of the posts occupied by newly appointed consultants but sadly Foundation Trusts vary in their willingness to engage with the RSPA, with some actively distancing themselves, but with others keen to embrace what the RSPA has to offer. This variation is not in the interest of patients and needs to be challenged. What is the commitment required to be an RSPA? The role overall is not particularly onerous. Attendance at the regular Regional Board meetings, perhaps three or four a year, is a fundamental requirement and in addition, national meetings, where a wide variety of relevant professional issues are discussed, are held once or twice a year. The running of regional specialty meetings is encouraged, and the College offers effective support through its Outreach teams. Approval of Job Descriptions for new consultant appointments is required as is attendance at Consultant appointment interviews with the volume of work varying according to region. So, in summary, the RSPA is a rewarding role but one with challenges; it offers some degree of autonomy but is extensively supported. If this sounds appealing and if a role becomes available in your region, think about applying – you may look back after seven years and be grateful that you did! First published at in May 2019

The BOA are currently seeking to recruit RSPAs for a number of regions to improve local standards and shape service delivery. Please see the Get Involved section of the BOA website if you are interested in applying: 28 | JTO | Volume 08 | Issue 01 | March 2020 |


National Orthopaedic Alliance – Improving quality in orthopaedic care Peter Kay and Philip Turner

Peter Kay is a Consultant Orthopaedic Surgeon at Wrightington, Wigan and Leigh NHS Foundation Trust, honorary Clinical Professor of Orthopaedic Surgery at Manchester University and honorary Professor in Orthopaedics at University of Central Lancashire. Peter has been President of the British Orthopaedic Association (2011), British Hip Society (2008) and British Orthopaedics Trainees Association (1992). He currently serves on the Council of The Royal College of Surgeons of England and Council of the Medical Defence Union, and is the National Clinical Director for Musculoskeletal services for NHS England. Peter is also the Clinical Lead for the National Orthopaedic Alliance (NOA).

The National Orthopaedic Alliance (NOA) is an organisation which brings together orthopaedic centres around the UK with the aim of reaching explicit and common high standards of care. Initially an NHSE vanguard, the NOA has grown into a network which exists to promote high quality outcomes for patients and better value for money through productivity and long-term cost savings. NOA’s founder member organisations include: • Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust • Royal National Orthopaedic Hospital NHS Trust • Royal Orthopaedic Hospital NHS Foundation Trust • Wrightington, Wigan and Leigh NHS Foundation Trust • Oxford University Hospitals NHS Foundation Trust (Nuffield Orthopaedic Centre). The NOA has now developed into a self-funding membership organisation of 16 Trusts or regional collaboratives who are committed to the aims of the alliance.

NOA’s role

Philip Turner is a Consultant at Stepping Hill Hospital, Stockport. He is a Council and Executive member of the BOA and was President from 2018 to 2019. He is also the founder and Chair of the GMOA, Clinical Lead for T&O Transformation in Greater Manchester.

The role of the alliance, and in particular how it has impacted its members since becoming a self-sustaining organisation following the end of the NHSE vanguard programme, is owed some focus. The NOA’s role is to work to improve orthopaedic care at a national level by supporting collaboration across its membership and providing a forum for members to share experiences and best practice. By encouraging members to work with and learn from each other, the organisation has acted as a catalyst for a range of improvement activities and meaningful conversations that have helped its members to be more efficient and effective. This shared learning, networking and best practice promotion is one of the foundations of the NOA’s offering.

Forums such as our quarterly meetings, which are attended by both clinical leaders and senior managers, have been instrumental in supporting this. Many collaborations, networking opportunities and shared projects have had their roots at our meetings and they continue to be an invaluable platform for having honest conversations about the real issues that affect providers of orthopaedic care and their patients across the country. In May 2019, following a presentation at one of our meetings by the Royal Orthopaedic Hospital NHS Foundation Trust (ROH) about the Trust’s hip and knee replacement service, JointCare – a group from fellow NOA member, Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) visited ROH to find out more about the programme. The visit was an opportunity for the WWL team to have a first-hand walk through of the service, and discussions between the Trusts have continued since. The NOA now offers a buddying scheme to aid development and improvement. One of the ways the NOA really comes into its own is through delivering an accurate and timely communication network. In collaboration with partners such as the BOA, we offer a voice at a national level, ensuring members’ perspectives on key issues reach a broader audience. We provide members with an overview of what’s coming in terms of national policy work and innovations within the sector. Added to this, we provide CPD accredited workshops, events and bespoke training and development opportunities, making the role of the NOA a hands-on and practical one – dynamic, wide ranging and responsive to hot topics and the needs of our membership. >>

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• We supported the development of a PROMS network with an aim to encourage members to work together to ensure that they, and their patients, are getting the most from PROMs through accurately and effectively capturing information. • Our latest Cost Improvement Programmes (CIP) workshop, which had representation from seven NOA member organisations was held in November 2019. The day included presentations from attendees highlighting CIP achievements, challenges and lessons learned as well as themed breakout focus groups. The workshop helped trusts to prepare for business planning 20/21. • Our procurement group continues to work with Category Towers to achieve the Figure 1: NOA members share experiences. A team from WWL visit ROH to find out more about the Trust’s best prices for Joint Care service. our members and support data analysis to provide price transparency across A look back at 2019 our membership for key items e.g. primary A quick look back at the last year shows THR prostheses. The group is also in contact just how the NOA, through this approach is with the GIRFT Procurement Lead to ensure making a difference to its members – and by we stay up to date and can leverage any extension orthopaedic care nationwide. identified opportunities. • Our work on tariff continued last year and is ongoing. The NOA commissioned detailed research which explains why we believe existing national tariffs are not fit for purpose for specialist orthopaedic care (carried out in both secondary and tertiary centres). Based on the NOA’s evidence and analysis with support from the BOA, the profession has engaged with NHSE and NHSI to agree on the need for substantial changes to be made.

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• Our Short Guide to Clinical Coding for Clinicians was refreshed in 2019 (originally launched in 2017 to positive uptake and reviews from members). The guide has been designed to provide insight into coding best practice. In line with the NOA’s focus on sharing best practice, the guide is an example of how by working in partnership, clinicians and coding teams can support high quality, safer care and more productive coding.

NOA quality standards The alliance was originally established based on a quality standards membership model founded on evidence-based descriptors of what ‘good’ looks like in orthopaedics. Written from a quality care perspective – covering both clinical and non-clinical areas, the NOA quality standards have been used as guidelines by members. They incorporate and complement established guidelines such as the BOA BOASTs and commissioning guides, NICE guidance and Getting it Right First Time (GIRFT) standards. The standards currently cover 28 areas of orthopaedic practice and have been developed in collaboration with our members for our members, using the best available evidence in order to provide them with informed recommendations that support quality orthopaedic care. We continue to expand the range of standards and have recently been discussing new ideas and potentially a new vision for how we develop them. Using data from the NOA benchmarking portal, the NOA regularly provides members with information to highlight areas they are doing well in, and where there is room for improvement. Where areas for development are identified, the NOA will buddy organisations from across the membership to support their improvement. NOA members can then use the quality standards as guidelines to measure the improvement in the quality of care they deliver. The NOA will offer ongoing support and training where required to ensure members are able to achieve the level of care they aim for.

Partners and collaborative working Encouraging collaborative working does not stop at our members, the NOA as an organisation works hard to ensure we are working and sharing with a range of organisations and stakeholders. Most of our clinicians are also members of the BOA, and as such working closely with the BOA is important to us. We have already benefitted from opportunities to work with the BOA on issues and projects that are important and relevant to both organisations and look forward to working with the BOA to achieve our common goal to improve quality in orthopaedic care across the country. The NOA coding team is working alongside the GIRFT Clinical Coding Project to deliver many common objectives. As part of this we are running a series of coding events in conjunction with the GIRFT Clinical Coding project team. The first event, a Clinical Coding Training day for non-clinical coders, held in spring 2019, gave attendees an understanding of clinical coding that will


Figure 2: Attendees at an NOA PROMS workshop.

enable them to work with their departments and directorates to improve the accuracy of their coded data. This will help to reduce inaccuracies with nationally compared data, payment and activity management without having to spend valuable resources on expensive consultancy services.

More than meets the eye One little known role of the NOA is the support we can provide to replicate our model. A key driver for all NHS vanguards was to create replicable blueprints that could be rolled out quickly elsewhere in the NHS to support new models of care. As single specialty vanguards, Moorfields Eye Hospital and the NOA had already developed a relationship through the national vanguard programme and it was natural that ophthalmology would be the first specialty to attempt to replicate the NOA model in year two of the vanguard programme. It was agreed that an ophthalmology alliance would be developed as part of the NOA vanguard programme in 2017-18, but driven clinically by the Moorfields programme team. The UK Ophthalmology Alliance (UKOA) held its first meeting in August 2017. The NOA supported this work and gave access to staff, processes and documents to allow the UKOA to base its plans on. UKOA would not have begun or been anywhere near as successful without the NOA’s support and without being able to build on what the NOA had already done.

The future Figure 3: NOA’s Short Guide to Clinical Coding for Clinicians was refreshed in 2019.

We believe that the future for the NOA is bright. In the coming year, we look forward to working on the below and much more.

• Continue to grow our membership • NHS Long Term Plan integration - extra funding from membership fees will enable us to look to the NHS Long Term plan issues that will have an impact on orthopaedics and extract from that to inform our activity. Areas of focus will include: – Workforce – AI solutions to improve theatre efficiency for our members – Continuous improvement – More work around CIP programmes to enable investigation of ideas to prepare our members for business planning 2020-21. • Tariff - continue the work we have been doing on tariff with an emphasis on NonSpecialist Tariff. • Sharing best practice - continue to promote sharing best practice by our members through our meetings, workshops and webinars. • NOA quality standards refresh - refresh the existing quality standards and add new standards. Not only will the work we do continue to benefit our members, but we believe, continue to be a blueprint for further replication across a range of specialities. n To find out more about the NOA or get involved with our work, visit: Follow us on Twitter @NOAOrthopaedics or email:

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Jamie Nicholson is a T&O ST5 in Edinburgh. He is a current Clinical Teaching Fellow for NHS Lothian and MD research fellow for University of Edinburgh.

Improving the undergraduate Trauma and Orthopaedic experience. Adoption of a modern teaching approach Jamie A Nicholson, Gavin Brown and Hamish Simpson

Over the past few years there has been a concerning decline in applications to surgical specialist training. This is combined with an increasing awareness that negative stereotypes of a speciality can influence a medical student’s ultimate career choice1,2. Gavin Brown is a T&O Clinical Lecturer and Honorary Consultant Orthopaedic Surgeon in the Department of Orthopaedic Surgery at the University of Edinburgh. He is a previous Clinical Teaching Fellow for NHS Lothian.

Hamish Simpson is Professor of Orthopaedics and Trauma, and Consultant Orthopaedic Surgeon in the Department of Orthopaedic Surgery at the University of Edinburgh, specialising in limb reconstruction, musculoskeletal infection and paediatric deformity.

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t is essential that Trauma and Orthopaedics is well represented at an undergraduate level and there is a compelling argument for fundamental knowledge to be delivered to all future doctors. Orthopaedic pathology constitutes approximately 25% of primary care consultations; osteoarthritis is one of the most prevalent chronic diseases and fractures are found in 90% of major trauma patients. Feedback for the Orthopaedic undergraduate fourth year rotation at the University of Edinburgh ranked poorly in comparison to other specialities. Teaching was delivered through didactic lectures combined with clinical placements that lacked focus and continuity. The introduction of a dedicated clinical teaching fellow led to an overhaul of the placement resulting in significant, sustained improvements. The block is now routinely rated as one of the most popular in the year and is used as an exemplar structure for other specialities to model their improvements around. In this article we would like to outline our strategy regarding module reforms as outlined in Figure 1.

Figure 1: Module reforms.

Learning objectives Undergraduate curriculums often expand unchecked and it is far easier to add new learning objectives than to remove outdated ones. The curriculum in Edinburgh was carefully evaluated by module leads from Orthopaedics and Rheumatology to avoid overlap. It was ensured that the content closely reflected the practical knowledge for a workload found in


the emergency department or primary care. Emphasis was placed on acquisition of clinical skills, recognition of common conditions and knowledge of the natural history of self-resolving conditions versus those which require specialist input. Treatment content focussed on optimising conservative management, decision making in non-traumatic conditions and principles of fracture care. The idea of a ‘spiral curriculum’ is useful for complex learning objectives3. This concept revisits a diagnosis or treatment principle in several different encounters in order to build in repetition and increasing depth of knowledge for important topics. For example, the limping child differential is introduced as self-directed reading, expanded in a tutorial and then reinforced with student led case-based discussions. Learning objectives should be clear, specific and closely aligned to assessments. Depth of knowledge was reflected in a star-based system. The BOA guidelines give clear suggestions on essential content which provided a useful reference4.

Active learning Whole class didactic lectures do not engage students and their limitations are becoming increasingly recognised5. Although a convenient way to deliver content they reinforce a ‘spoon fed’ mentality and do not engage students in the shared responsibility and ownership of their learning. The idea of the ‘flipped classroom’ is a way of engaging medical students with active learning (Youtube ‘Eric Mazur flipped classroom’ for more information)5,6. Students do their pre-tutorial reading and tasks beforehand (homework in the traditional sense) and arrive to the tutorial with a baseline level of knowledge which is expanded on with group discussion and active engagement. The use of ‘ask the audience devices’ ensures engagement. We use tablet devices with a university supported audience

response application (TopHat) which allows questions with images or other multimedia (Figure 2 & 3). The hidden agenda of this strategy is the requirement for students to discuss the material in small groups which promotes peer discussion prior to committing to an answer. To run a tutorial successfully requires the tutor to be aware of both the content and the technology involved. Focus is constantly alternated between short segments of information delivery and questions that lead to group discussion. It is an extremely effective way to run tutorials and there is evidence that peer discussion allows ideas to be understood more easily. For example, a student who has just grasped a difficult concept may have a good appreciation of the barriers to understanding this topic for their peers.

Figure 2: Lower limb – case 1.

Figure 3: What else can be done in an emergency department.

Figure 4: Timetable for orthopaedic teaching four-week rotation.

Prior to each tutorial, students are given a handbook of learning objectives, useful resources and questions, which are then explored during the tutorial itself. These tutorials include trauma (ATLS), orthopaedic emergencies, fractures, elective conditions, paediatrics, spine and tumour.

“Over 100,000 knee replacement procedures are performed each year in the UK, with patient dissatisfaction a factor in up to 20% of cases. There is also considerable variation in the approach to investigating and treating this difficult patient group.”

Clinical placement and selfdirected learning If your orthopaedic modules are two weeks or longer, there is an excellent opportunity to ensure continuity with named consultant tutors and their respective registrars. We have found this creates accountability with students when they are known to a specific team and more importantly

ensures a relationship is developed, aiding the value of the placement. Given the sub-specialisation of consultant practice, students are allocated a consultant co-tutor with a complimentary practice for variety. An introduction and orientation meeting to the department is crucial. If this cannot be performed by a clinician, then a named administrator may be equally appropriate. Students receive a tutorial and clinical placement timetable for the four-week rotation and are given a degree of autonomy regarding which clinical activities they attend out with whole-class tutorials (see Figure 4). Building opportunities for meaningful selfdirected learning has proved very popular. We have introduced a clinical workbook >>

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which explains the clinical environment and the potential learning opportunities (e.g. theatre, fracture clinic, emergency department etc.). Within this book is a map of the department, useful resources and learning objectives mapped to the clinical environment. This would be a good project for a registrar interested in education to complete for your own department. Completing the workbook is optional but incentivised by a ‘question and answer’ session to go over difficult concepts from the workbook which is usually attended by approximately two thirds of students. Clinical sign up sessions have proved a useful addition for variety in the block and to keep students engaged in the event of tutor absence. These feature ‘on-call’ sessions with the junior registrar, paediatric clinics, additional trauma theatres or specialist elective clinics. A simple online sign up system means organisation is low maintenance. More recently, we have started to expand our online virtual learning environment with easily accessible examination videos, summary slides for common conditions and links to useful resources.

Figure 6: End of year student feedback.

Regular feedback to students and tutors Regular feedback for students is crucial for development. We have tried to build in regular opportunities for both formal and informal feedback on the block. The development of a mobile phone application for history and examination practice has proved useful (See Figure 5). The ‘peer practice’ app gives objective feedback criteria for specific clinical encounters and common OSCE stations. This can be used to generate feedback either by tutors or by peers. We have combined this with a ‘peer review OSCE’ at the end of each block. Students review simulated patients in groups of five, each one takes a turn to complete a station whilst the other observe and provide feedback. It can be easily facilitated by one tutor without the labour, resource or time demands of running a traditional mock OSCE for individual students during each block. Given the excellent continuity that students now have with their tutors we have introduced a simple end of block sign off to allow for reflection of a student’s engagement and knowledge acquired during the block.

Figure 5: Screen shot of knee exam from mobile phone app.

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It is important to recognise the efforts of consultants who contribute considerably to the clinical placement. We have tried to gather feedback from students regarding their experience with individual tutors and periodically summarise this to the whole department with examples of exemplary registrars and initiatives (e.g. creation of a WhatsApp group with the students for updates on clinical activities).

Disseminating the University feedback on the high performance of the block is also a useful way to retain engagement and provide evidence for revalidation.

Evidence of improvement End of academic year feedback gathered by the University was used to track evidence of sustained improvement to the block. Free text and qualitative feedback indicated the desired effect of engagement in the interactive tutorials, student autonomy and continuity with the clinical tutor. A breakdown of the feedback is given in Figure 6 with the percentage of students rating the domain as excellent or very good over the last five years. We have seen a marked increase in the number of students wishing to undertake research projects and elective placements in the department. The University now has an undergraduate Orthopaedic Society, closely supported by the department, which runs a national conference and several training events throughout the year.

Conclusion A modern approach to curriculum delivery has led to a sustained and ongoing improvement in the orthopaedic block. Our approach may be of value for other University surgical departments to identify key areas and methods for improvement. n

References References can be found online at


Anh Nguyen is an Orthopaedic Registrar and a Black, Asian, Minority and Ethnic (BAME) recruitment panel representative at St George’s University Hospitals NHS Foundation Trust. She is a Clinical Teaching Fellow and Post graduate student representative for the St George’s University of London.

Caroline Hing is an Orthopaedic Surgeon and Honorary Reader at St George’s University Hospitals NHS Foundation Trust. She is a member of the BOA Equality and Diversity Working Group and BOA Education and Careers Committee.

Alex Trompeter is a full-time orthopaedic Trauma Surgeon specialising in fracture surgery and the management of post fracture complications. He is an Academic and Educational Supervisor and Training Programme Director for the South West London Orthopaedic rotation, and is passionate about education.

Less than full time training: Being a parent and an orthopaedic trainee Anh T V Nguyen, Caroline B Hing and Alex Trompeter

A number of female doctors in the United Kingdom (UK) report orthopaedic training being incompatible with family life1. This perception may stem from a lack of awareness and understanding around less than full time (LTFT) training in orthopaedics. We outline how LTFT training operates and the support available to LTFT trainees in orthopaedics.


TFT refers to specialty training with a reduced number of hours (usually not less than 50% of full-time). Although more female trainees are taking part in LTFT training than their male counterparts; this option is available to both genders. Rationale for LTFT training requests are grouped into categories based on need, with childcare a prioritised reason for acceptance. Within the South West London rotation, in addition to support provided by the Training Programme Director (TPD) and Academic and Educational Supervisor (AES), the trainee can be connected with a mentor who has LTFT experience for additional guidance. Communication with the AES, TPD and mentor is crucial to a positive LTFT training experience, throughout all stages from pregnancy, parental leave and on return to work. During pregnancy, an agreement can usually be made between the trainee, their AES and the local occupational health department as to which clinical activities are safe – such as on call, manual handling, and exposure to ionising radiation. During this stage, the parental leave application is made. During leave, the trainee can remain engaged with the training programme. For example, keep-in-touch (KIT) days are a paid facility of up to 10 supernumerary days that the trainee can take to attend teaching or supervised clinical sessions to build confidence prior to their return to work date. Towards the end of the parental leave period, trainees have a meeting with their AES and TPD to facilitate a supervised return to work period. Specific

details of training policies and resources can be found in the national training reference guide or the ‘Gold Guide’2 and the ‘Supported Return to Training’ (SuppoRTT) guidance document3. In addition to local support, there is an increasing network of support nationally. The British Medical Association has set up a LTFT forum4 that hosts regular conferences and provides pay and rostering guidance via a dedicated regional representative. The Joint Committee on Surgical Training are working to improve the LTFT training experience for trainees based on the recommendations from various trainee organisations. Despite the above initiatives, there is scope for improvement. Firstly, the current guidelines could provide clearer guidance regarding the length of recommended parental leave. Stack et al.5 reported that trainees with at least two months of maternity leave were less likely than peers to suffer post-partum depression and burn out. Secondly, it is suggested that on-site lactation and child care facilities can help more women to stay in full time work in orthopaedics6. LTFT training is likely going to be a popular option amongst future trainees. Initiatives to improve LTFT trainee’s experience will increase career satisfaction of our surgeons and attract more female applicants into orthopaedics. n

References References can be found online at

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The Birmingham Orthopaedic Network – Collaboration, facilitation, empowerment Usman Ahmed

Usman Ahmed is a Consultant Orthopaedic Surgeon with a special interest in Lower Limb Revision Arthroplasty at the Princess Royal Hospital, Telford. The Birmingham Orthopaedic Network was developed in his final year of training in Birmingham and as a BOA Clinical Leadership Fellow in 2017/18�.

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The past decade has seen a rapid growth of trainee collaboratives. The West Midlands Research Group (general surgery) led the way and demonstrated the effect of empowering driven trainees in research. Since then trainees have played a significant role in studies starting with recruitment of patients to major studies through to developing and receiving funding for trainee-led projects. This has not gone unnoticed and has the broad support of consultant and research bodies.


he Birmingham Orthopaedic Network (BON) has its roots in the traditional collaborative model but has been expanded to promote wider engagement beyond surgical trainees. In addition, the model has sought to facilitate training and education as part of a broader drive towards an improved and engaging culture. The proposal for the BON (August 2017) initially achieved broad stakeholder support on a local and regional level. With support from the Birmingham Orthopaedic Training Programme, the Royal Orthopaedic Hospital and Health Education England.

From the outset infrastructure was developed towards three strategic aims: 1. To facilitate collaborative working with robust protocols and policies to enable rapid development, assessment and implementation of audit/research projects. 2. To develop a pathway to allow medical students to actively participate on traineesupervised projects. 3. To build an educational platform. In the almost two years since its inception the BON has garnered widespread local, regional and national support and trainees


“As a testament to its rapid growth and early successes, the BON was a finalist at the Health Service Journal Value Awards 2019 in the Training and Development Initiative category.”

have taken a proactive lead in national project development and implementation (DRAFFT Impact Study), been willing partners in other national projects (FEMOR study, UCES study) all of which have been presented to both national and international audiences. The medical student engagement has seen approaches from both individuals and groups of medical students to foster even closer links following the particular success of the initial cohort. The educational platform continues to grow with archived material for junior doctors and medical students serving as a precursor to wider engagement with all healthcare professionals involved in musculoskeletal care. As a testament to its rapid growth and early successes, the BON was a finalist at the Health Service Journal Value Awards 2019 in the Training and Development Initiative category.

to get involved in quality work without necessarily following the more arduous academic pathway. At a time when the NHS faces unprecedented difficulties in recruitment and retention the training and development aspect of the BON was designed to encourage and engage the surgeons of tomorrow. Trainee collaboration has been demonstrated to be a powerful tool in clinical research. But when empowered there are very few limits to what trainees can achieve. In the current NHS the drive towards cultural improvement should include giving junior staff (in any field) encouragement to develop ideas and opportunities to implement them. As such the BON has succeeded in its key objective to facilitate and empower and will continue to do so. n To find out more about the BON visit:

The further expansion of the BON is intended to continue with a view to encouraging participation from anybody and everybody who has an interest in musculoskeletal health. This open policy and desire to engage and participate in projects is representative of trainee desires

Why do surgeons bother with research? Chris Bretherton


t’s probably less carrot than stick… Our governing bodies require research output at every stage of career progression. Presumably, this is to demonstrate our ability to interpret literature and practice evidence-based healthcare. Does publishing a retrospective series of your boss’ last 20 bunion operations achieve this? Fortunately, the BOA has helped shift the goalposts, realising that low-quality research is neither helpful to ourselves or the scientific community. The 2018 shift in research requirements for T&O Certificate of Completion of Training (CCT) now encourages surgeons to integrate research into their every-day practice, through involvement in multi-

center clinical trials. This is a more efficient method of generating highquality research in the NHS. Being a local principal investigator (PI) for a clinical trial will provide greater insight into research design and interpretation than the low-quality papers we were previously incentivised to produce. The ‘associate PI’ scheme is a joint venture between the National Institute of Health Research (NIHR) and the Royal College of Surgeons of England. It provides guidance and accreditation for trainees wishing to contribute to NIHR research. Furthermore, trials units are making the process easier by automatically providing certificates for participant recruitment, which trainees can use as evidence towards their CCT.

Trainee research collaboratives are emerging in all regions, with notable examples from Birmingham, Peninsula and Northern Deaneries. Each has its own model for encouraging research, education and mentorship. Combining their efforts, they have won major grant funding for high quality, trainee-led trials. All in all, these changes mean that weekends spent data mining and resubmitting papers to gain CCT will soon be a thing of the past. The new incentives promote meaningful engagement in research, which equals happy surgeons and happy patients. n

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What is consent? John de Bono

The Paterson Inquiry has brought renewed scrutiny of the relationship between surgeon and patient. The fifth anniversary of the Supreme Court’s landmark decision in Montgomery is a good time to review the current state of play on the law of consent and the implications for surgeons.


John de Bono QC is a leading clinical negligence barrister practicing from Serjeants’ Inn Chambers in London.

o understand Montgomery we need to take a step back and recognise how things used to be. In what some will still regard as the good old days, it was for the surgeon rather than the patient to decide on what treatment was required. Advice was acceptable, and a surgeon was not negligent, if he acted in accordance with the practice of a reasonable body of surgeons in the same field. In practice this meant that doctors could choose how much information to give a patient and whether to give options for alternative treatments.

Montgomery was short (under 5ft) and had diabetes. She therefore had a 10% risk of the birth being complicated by shoulder dystocia and if that happened there was a 10% risk of serious harm to her baby, giving a one per cent overall risk of serious injury to the baby from a vaginal delivery. Her obstetrician’s preference was for a vaginal delivery. She told to the court that she believed that if offered the choice Mrs Montgomery would have opted for the caesarean section. Mrs Montgomery duly had her vaginal delivery, the baby became stuck and suffered a serious hypoxic ischaemic brain injury.

This approach was endorsed by Lord Diplock in Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital decided in 1985. His view was that patients might be put off by a detailed discussion of risks and it was up to a doctor to decide how much information to provide:

The Supreme Court accepted that the obstetrician had acted in accordance with the practice of a reasonable body of obstetricians. Moving the goalposts significantly they found that this was no longer the correct test. The question is not whether a reasonable doctor would have offered different treatment but what a reasonable patient would want to know. If there are reasonable alternative treatments then a patient is entitled to know and to make her own choice. The court held:

“The only effect that mention of risks can have on the patient’s mind, if it has any at all, can be in the direction of deterring the patient from undergoing the treatment which in the expert opinion of the doctor it is in the patient’s interest to undergo.” As an overall approach this was the highpoint of paternalism in medicine. There was also an element of snobbery in the judgment. Lord Diplock observed that if an educated patient such as a barrister or judge had any concerns about the proposed treatment he would have the ability to ask appropriate questions of his surgeon. Everyone else need not worry. Sidaway remained good law until Montgomery in 2015. The facts of Montgomery are now well known. A choice had to be made between an elective caesarean section or vaginal delivery. Nadine

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“The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” This ruling has significant implications for trauma and orthopaedic surgeons. If elective surgery goes wrong a patient can argue that they would not have had the operation had they been properly advised of alternative options. Postoperative infection following hip replacement might be a recognised non-negligent complication of surgery but a patient who was not advised of that risk or of the alternative treatment options, including not having surgery, has a prima facie case in negligence.


Lawyers will tell you that consent cases used to be rare in practice. This was because even if a breach of duty was established a patient would struggle to prove what we call ‘causation’. If you give me sub-standard advice I have to prove that I would not have had the same operation with proper advice. Here too the goalposts have moved significantly in favour of the litigant. In Thefaut v Johnston, 2017, Mr Justice Green, found that a patient had not been given adequate advice about spinal surgery. Had she been properly advised she would either have not had surgery at all or would have had surgery on a different date. She was therefore entitled to damages for the disability that resulted from the otherwise nonnegligent complication of a dural breach.

they decided to go ahead with surgery but on a different date the rare, non-negligent complication, would probably not have happened. Many surgeons struggle with the logic of this position, arguing that if you suffer a complication of surgery on Monday you would probably have suffered the same problem with the same operation on Tuesday.

“The only effect that mention of risks can have on the patient’s mind, if it has any at all, can be in the direction of deterring the patient from undergoing the treatment which in the expert opinion of the doctor it is in the patient’s interest to undergo.”

A claimant who suffers a non-negligent complication of elective surgery need now only prove that had they been given appropriate advice about risks or treatment options they would have delayed surgery to ‘think over’ their options. The court will find that had

So how do surgeons protect themselves? Patients will often be convinced that there was no discussion of risks or alternatives. Surgeons need to be careful to record in a letter or the clinical notes that the patient was given a choice and what the alternatives were.

Advice needs to be specific to the patient. The risks of hand surgery might be different for the pianist and the barrister. The courts have left unanswered the obvious question of the surgeon: how great a risk need be to require a mention. It is not just a question of risk but the seriousness of the consequences and the implications for a particular patient.

Perhaps inevitably the Supreme Court kept its options open as to how great a risk need be to require a mention. It is not just a question of risk but the seriousness of the consequences and the implications for a particular patient. In Thefaut the judge gave the following guidance for surgeons consenting patients: • The dialogue between doctor and patient must be ‘adequate’. • There must be ‘adequate time and space’ for there to have been a reasonable dialogue. • Communication must be ‘de-jargonised’. • The doctor’s duty is not fulfilled by bombarding the patient with technical information. • The routine demand of a signature on a consent form does not by itself mean anything in terms of consent. • Consent should not be taken for the first time on the day of surgery. Of course where your patient is unconscious or exsanguinating all bets are off and the court will be quite happy for you to revert to exercising your best paternalistic judgement as to what to do. That may be some reassurance, at least to the trauma surgeon. n Note from the Editor: A follow-up article is planned addressing how the law stands with regards to consent for the non-elective but conscious patient typically encountered in trauma practice.

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Trainee Section

Supporting orthopaedic trainees returning to training after taking time out of programme Tricia Campbell

The orthopaedic training pathway is competitive. More trainees are seeking time out of programme to pursue interests, such as leadership, research or education. They may also have caring responsibilities or take parental or sickness leave. In order to fulfil these roles and pursue extra-curricular interests, trainees need flexibility and a certain degree of control over their working lives.


his flexibility has the potential to also ultimately benefit patients and create a diverse workforce of wellrounded individuals to serve our diverse patient population. Allowing trainees the flexibility to take time out of training will enable formation of a diverse workforce1.

Tricia Campbell is President of the British Orthopaedic Trainee’s Association (BOTA). She is currently out of programme working as a Leadership Fellow at HEE NE (Health Education England, North East).

To facilitate such time out of training, we need to also consider the issue of safe transition back to the clinical workplace. It can be a daunting experience for many trainees, regardless of their training level, to return to an unsupervised trauma list or a night shift in a busy major trauma centre after a period of absence. A recent survey of all General Surgery Higher Speciality trainees in the Kent, Surrey and Sussex (KSS) region identified key concerns regarding their return to training around their operative skills, confidence, worklife balance, clinical knowledge and perceptions of colleagues2. These findings are consistent with the results of a survey conducted by the AoMRC in 2016, which found the following specific concerns: • Attrition of clinical knowledge and practical skills. • Expectation of immediately being able to function at pre-level when resuming work. • Working out of hours without supervision from the outset. • Worries about missed new developments and changes in local and national guidelines3.

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To support sustainable careers and wellbeing, we need to normalise time taken out of programme and ensure that surgical career progression accommodates for trainees who wish to do so. In essence, we need to ensure that trainees wishing to take time out of training are not disadvantaged by their decision. As part of the ACAS agreement in May 2016, Enhancing Junior Doctor’s Working Lives group reported the importance of providing equity to those who have had a period of absence4. In response to this commitment, Health Education England (HEE) have developed a programme to support trainees returning to the work place following a period of absence over three months (opt in available for those less than three months). Trauma and Orthopaedic trainees that take up the programme are low in numbers, despite having a lot to gain from the Supported Return to Training (SuppoRTT) programme. The aim of this article is to raise awareness of the challenges that trainees face when they return to training and to highlight the support available.

The areas of concern Orthopaedics is a craft-based specialty requiring hands on learning to gain experience and allow for training progression. The concern is that time away from the operating theatre will lead to a diminution in operative skills. In 2014, the GMC published the ‘skills fade’ review. This review of the evidence found that

Trainee Section

clinical and professional skills fade. They found “substantial evidence that time out of practice does impact on skills retention. Skills have been shown to decline over periods ranging from 6 to 18 months, according to a curve, with a steeper decline at the outset and a more gradual decline as time passes�5. An example within the orthopaedic practice is measurement of knee and shoulder aspiration skills retention learned by simulation in medical residents between 6 to 30 months post teaching event. They found that proficiency declined over time. It was also demonstrated that an opportunity to practice similar skills in the interim can positively influence retention of a learned skill6.

The support available The Supported Return to Training Programme (SuppoRTT) was developed to enhance the experience of doctors returning to clinical practice. It enables them to regain their confidence and previously required skills quickly and safely. This in turn significantly benefits patient safety and quality of care. It has been designed to be flexible

and takes into account the length of absence as well as the speciality and experience of the trainee. The programme is designed to ensure that the individual can safely and confidently return to practice3,7.

The SuppoRTT star (Figure 1) illustrates the HEE offering: peer-to-peer mentoring, coaching, return to training activities, testimonials or case studies, guidance documents and signposting of useful resources.

Figure 1: The SuppoRTT star.

SuppoRTT uptake and funding co-ordinated regionally with national HEE oversight The delivery of the programme has regional differences but should include a series of meetings with your supervisor prior to, during and after your period of absence. The purpose of these meetings is to establish your individual needs and plan your return. This plan may include a period of enhanced supervision, supernumerary period, supervised on-calls, clinical immersion, a phased return (with or without occupational health input), workbased assessments in addition to generic return to training and specialty specific refresher courses. Your individualised return to work requirements, as agreed with your educational supervisor or training programme director (region dependent), will be funded by the SuppoRTT Programme through the meetings via submission of forms signed by selected supervisors.

Eligibility To be eligible for the funding, trainees must be on a training programme with a National Training Number (NTN) or accepted onto a training post due to start after their period of absence. Their absence should be over

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Trainee Section

three months in duration (although those with shorter absences may opt-in) and less than two years. All eligible trainees are encouraged to engage with the SuppoRTT programme7.

Education and training There is an abundance of courses covering the generic skills trainees across all specialities may require, (see Table 1). There are also a Generic Skills Return to Training Courses Work life balance and managing your time effectively Communicating with confidence Conflict resolution and assertiveness Dealing effectively with change Human factors training Building resilience Productivity in focus Exam game plan Coaching and virtual coaching

number of specialty specific courses available. These include, GASAgain (Anaesthetics), Springboard (Medicine), Return to Clinical Practice for General Surgery (Imperial College London) and Paediatric Return to Acute Clinical Practice (Paediatrics). Various learning modalities are being utilised including simulation, clinical updates, small group learning and scenario-based discussion. There are slight regional differences in the courses available. This often depends on local specialty focus on education and training. All regions offer training for supervisors and helps upskill them in preparation for supervising trainees returning after an absence. It can also help them deal with potential challenges and introduce them to local support and guidance. There is currently a lot of work being done to ensure T&O trainees can benefit from the SupoRTT programme. An orthopaedic specific return to training course is being piloted in May 2020. If you would like more information please contact the National HEE SuppoRTT Fellow (details below).

Return to training cross-specialty day


Clinical leadership courses

Increased awareness is paramount in shaping the culture around returning to training. The T&O community need to recognise the

Table 1.

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difficulties faced by trainees transitioning back into clinical practice after a period of time out of training. We need to help these trainees during their time of need and ensure that they are not disadvantaged as a result of their decision to take time out of training. There is support available for any trainee taking time out training. Please ensure that you contact your local HEE office for further information. n

Useful resources: National: Other: applying-for-a-job/returning-to-clinicalpractice-after-absence/a-model-process. National HEE SuppoRTT Fellow: Sarah Siddiqui, E-mail:

References References can be found online at

Subspecialty Section

Diversity: Women in orthopaedic surgery – a perspective from the International Orthopaedic Diversity Alliance Jennifer A Green, Vivian PC Chye, Laurie A Hiemstra, Li Felländer-Tsai, Ian Incoll, Kristy Weber, Margy Pohl, Carrie Kollias, Katre Maasalu, Magaly Iñiguez, Dafina Bytyqui, Margaret Fok, Philippe Liverneaux, Elham Hamdan, Violet Lupondo and Caroline B Hing


Jennifer Green is an Orthopaedic Surgeon in Canberra specialising in hand and wrist Surgery, Chair of the Australian Orthopaedic Association (AOA) Orthopaedic Women’s Link (OWL) Committee and one of the two observers of the AOA Board of Directors. She is the AOA Representative to the Diversity Council of Australia.

Vivian Chye is Consultant Orthopaedic Surgeon at Hospital Kuala Lumpur Hospital, Malaysia. Vivian is President of the Malaysian Orthopaedic Association and Vice President of the ASEAN Orthopaedic Association.

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he International Orthopaedic Diversity Alliance (IODA) was formed in 2019 by a network of orthopaedic surgeons who are advocates of cultural and gender diversity. It promotes the sharing of information between nations regarding strategies to improve diversity and the inclusion of females and minorities in orthopaedic surgery. The focus of this article is to explore the current gender statistics, the barriers and the advocacy efforts towards improving gender diversity with the evidence supporting these initiatives.


Leadership is the essential enabler for the four most effective diversity initiatives:9,10 1. Communicate and embed values, behaviours and cultural norms. 2. Ensure recruitment/promotion processes are unbiased and involve diverse decision makers. 3. Create working models that support males and females with families. 4. Visible and committed leadership.

Unconscious bias and the ‘hidden’ curriculum

Diversity is essential to creating strong organisations that maximise the talents and skills of their membership. Organisations that are diverse are able to attract top talent, increase innovation and exhibit a better quality of decision making1. The critical mass for effective diversity is 30% across the fields of medicine, business and politics2-4. Diversity within orthopaedics was recently addressed at an international level5 and we aim to provide an expanded perspective. Although females represent >50% of medical graduates in many nations, females still often constitute <10% of orthopaedic surgeons, and orthopaedics remains the least gender diverse of all surgical specialties.

The past 30 years has seen progress in uncovering the implicit biases11, which have negative consequences for our choices of trainees, colleagues and patient treatments12. They underpin the ‘hidden’ curriculum13 - the unwritten, unofficial values and perspectives that students learn14,15. In many nations the hidden curriculum teaches that orthopaedics is a ‘boys club’, that you cannot be a mother and an orthopaedic surgeon and that work-life balance is difficult. This plays an important role in inadvertently deterring good candidates from considering orthopaedic surgery. As an example of unconscious bias, this article has omitted non-binary genders. The authors acknowledge this shortcoming.

The competence of females is not in question with studies demonstrating patients of female surgeons have fewer complications and lower mortality6,7. Many barriers exist to increasing the numbers of females in orthopaedics including: gender bias; lack of exposure to surgical specialities during training; lack of mentorship and; lifestyle concerns8. The international data presented provides a gender diversity improvement framework.

In 2009, a study of attitudes in the UK demonstrated that 24% of female medical students would consider a career in orthopaedic surgery. Female students were more likely to be exposed to negative attitudes against female surgeons and 62% of those who were exposed to such attitudes wouldn’t consider a career in orthopaedic surgery. 42% of male surgeons had been exposed to negative attitudes against female surgeons, including

Subspecialty Section

Laurie Hiemstra is an Orthopaedic

Surgeon at Banff Sport Medicine Canada. She is a member of many organisations including the International Society of Arthroscopy, Knee and Orthopedic Sports Medicine (ISAKOS), the Arthroscopy Association of North America (AANA), the American Orthopedic Society of Sports Medicine (AOSSM), and the Canadian Orthopaedic Association (COA).

Table 1: Analysis of gender diversity per nation.

Li Felländer-Tsai is Professor and Chair of Orthopaedics at Karolinska Institutet, senior Consultant in Orthopaedic Surgery at Karolinska University Hospital in Stockholm, Sweden, 2nd Vice President EFORT and Past President of the Swedish Orthopaedic Association.

questioning of their skill and the perceived conflict between their clinical and family responsibilities. Despite the marked gender differences expressed by medical students and specialists, when patients were questioned, 89% had no gender preference16. Providing opportunities for medical students to engage with orthopaedic surgeons who are positive role models for gender diversity is one mechanism for changing this hidden curriculum.

Lack of female role models

Ian Incoll is Conjoint Professor at the University of Newcastle, Australia, Australian clinician educator and Orthopaedic Surgeon. He is Dean of Education and a Past President of the Australian Orthopaedic Association. He was the lead developer for AOA 21, the innovative and contemporary redesign of Orthopaedic Surgical Training in Australia.

Strategies to increase diversity include: early exposure to the speciality field; mentoring; interaction with female specialists and; an institutional culture supportive of females17-19. Orthopaedic training programmes with greater representation by female faculty have a higher proportion of female trainees. However, males who are good advocates and mentors for females are equally effective. Cross-gender mentoring is vital to achieving equity and should be an aspiration for all males20.

Gender equity in selection processes Gender equity in selection processes varies between nations. In Australia, New Zealand

and in several USA orthopaedic programmes, increasing diversity is taken into consideration in the selection process with candidates who otherwise rank equally. Many nations such as the UK have evidence of steadily increasing female orthopaedic applications, but this is still significantly less than for other specialties.

Flexibility in training and parenting Significant barriers are perceived to pursuing a surgical specialty by females who want to have a family. A recent survey of 10,000 female medical students by the Royal Australasian College of Surgeons (RACS) showed the main barriers included lack of time for family and friends, current or future children and the lack of flexibility of training21. Similarly, a USA study of 720 students showed that surgical work hours and lack of time for outside interests were the greatest deterrents to pursuing a surgical career. Female medical students demonstrated greater concerns regarding finding time to date, marry and have children during residency. Female students were more likely to perceive that discouragement from pursuing surgical training was based on gender, age and family aspirations, as compared to males22. >>

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Subspecialty Section

Kristy Weber is the Abramson Family Professor of Sarcoma Care Excellence and Vice Chair of Faculty Affairs in the Department of Orthopaedic Surgery at the University of Pennsylvania. She is the Director of the Sarcoma Program at the Abramson Cancer Center and currently serves as the President of the American Academy of Orthopaedic Surgeons.

Table 2: Analysis of the pass rate from the American Board Exams by gender and parity.

A paper analysing the pass rate from the American Board Examinations in Surgery demonstrates that the examination results of male surgical trainees are unaffected by their marital or parenthood status, and single female surgical trainees outperform their male peers. However, their pass rate drops below male peers when they partner and decrease further when they have children23.

Margy Pohl is Clinical Director of Orthopaedics at Northland DHB, Whangarei, New Zealand; a valued member of the NZOA Council and Chair of the LIONZ initiative.

Carrie Kollias is Paediatric Orthopaedic Consultant at Royal Children’s Hospital, Melbourne.

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Social policies supporting pregnancy and childrearing allow a greater participation of females in the surgical workforce. Sweden and Estonia have the highest rates of female participation in orthopaedics and the most generous parental leave and progressive social policies.

Pregnancy and breast feeding There are health and safety concerns in orthopaedics that are unique to females. The occupational hazards of exposure to radiation and Methyl methacrylate (MMA) in orthopaedics are well-recognised but can be minimised. A double layer of lead can be worn in pregnancy24,25. MMA has also been shown to be feto-toxic at levels >1,000 ppm. Appropriate use of vacuum mixing and protective helmet systems have been shown to minimise exposure to MMA26. More insidious are the effects of long working hours and night shifts on the health of pregnant surgeons. In female surgeons who work more than 60 hours per week, the odds of preterm labour and delivery are 4.95 times higher than average pregnant females in the USA. The risk of complications of pregnancy are higher in female orthopaedic surgeons (31.2%) compared to the general population (14.5%)27. Evidencebased policies must be instituted to protect the well-being of pregnant surgeons, including

limiting working hours and decreasing night shifts. The Specialty Trainees of New Zealand (STONZ) have well-established guidelines28.

Female inclusion in scientific and educational meetings Evidence shows that diversity at scientific meetings leads to better science10,30,31. Participation in scientific meetings is important for professional development, provides opportunities to collaborate and expand professional networks. Convening, moderating and participating in panels and presentations at scientific meetings are key roles that afford recognition and standing among orthopaedic peers. Female surgeons are often the primary carers in early childhood, a role that can severely limit their participation in scientific meetings. The availability of breastfeeding rooms and childcare facilities at all orthopaedic meetings would enhance their participation. A guide with practical methods to improve diversity and inclusion in scientific meetings provides evidence-based methods to improve diversity and inclusion in scientific meetings29.

Females in orthopaedic leadership roles Females are under-represented in leadership roles in their early career years. For orthopaedics this includes executive and board positions in professional associations. However, there are currently at least four female orthopaedic association presidents in the USA, Malaysia, Sweden and Estonia. It is vital that more females are mentored and sponsored into these leadership roles. With the predominance of male orthopaedic surgeons in leadership roles, it is critical that males are engaged in this process.

Subspecialty Section

Katre Maasalu MD, PhD, is an Orthopaedic Surgeon at Tartu University Hospital, Estonia and President of the Estonian Orthopaedic Association.

Table 3: Guidelines for working whilst pregnant (New Zealand).

International representation of females in orthopaedic surgery and strategies to improve gender diversity

Magaly Iñiguez is an Orthopaedic Surgeon in Chile. Magaly is Founder of the Association of Chilean Female Orthopaedic Surgeons, Member of the Scientific Committee and the Gender and Diversity Task Force Committee at ISAKOS.

Dafina Bytyqui is an Orthopaedic Surgeon working in Kosovo.

Strategies to improve representation of females in orthopaedics are centred around reducing or eliminating the known barriers. Organisations must provide a safe, unbiased environment and push for equity of opportunity for female and minorities by encouraging mentorship and role modelling. Changing the traditional orthopaedic culture allows both genders a better family life and will improve work-life balance. Africa and Tanzania: According to the World Health Organization, Africa has a predicted need for 3.7 million health workers in order to provide universal health care by 203032. In Tanzania 7.6% of the nation’s 118 orthopaedic surgeons were female in 2019 and of the 51 orthopaedic trainees, 5.8% were female33. The main focus in the medical workforce has been to improve the doctor-patient ratio through the increased enrolment of medical students. The College of Surgeons of East, Central and Southern Africa (COSECSA) is the largest surgical training institution in Sub-Saharan Africa. There have been 340 surgeon graduates since 1999 and the goal is to have 500 graduates in 2020. There are currently 575 surgeons in training. Women in Surgery Africa (WiSA), under the umbrella of COSESCA, has established a mentorship programme. The American College of Surgeons (ACS) has provided a strong commitment to WiSA and supports female surgical trainees across the region. Asia, Malaysia and the Philippines: Prior to 2000, female orthopaedic surgeons were unusual in Asia. The turn of the millennium saw an increasing presence of females in orthopaedic practice and training all over Asia. Dr Tunku Sara Ahmad Yahaya founded the Hand and Microsurgery Unit in the University of Malaya in 1993. She became the first female President of the Malaysian Orthopaedic Association (MOA) in 2006. She was the only female orthopaedic surgeon in Malaysia until

1999 when two other females qualified from the National University Malaysia. In 2000, three more female orthopaedic surgeons graduated. Since then, there has been a steady increase of females in the orthopaedic postgraduate programmes. In 2014, Dr Azlina Abbas, became the second female President of the MOA, followed by Dr Chye Ping Ching in 2019. In 2020, she will become the first female President of the ASEAN Orthopaedic Association. Dr Sharifah Roohi shall become the fourth female MOA President in 2020. Dr Teresita L Altere from the Philippines qualified as an orthopaedic surgeon in 1971, and became the President of the Philippines Orthopaedic Association (POA) and the first female in Asia to be the president of an orthopaedic association in 1986. Dr Virginia C Cabling became the second and Dr Julyn A Aguilar became the third female Presidents of the POA. Australia: In 2018 the Australian Orthopaedic Association (AOA) established a diversity strategy to address the persisting lack of gender diversity. The key AOA initiatives include: • Supporting females into leadership roles – the AOA Board is now 40% female. • Advertising AOA Committee roles – 12% are now held by female members. • Actively seeking representation of females at AOA scientific and educational meetings with policies to increase inclusion. • Providing childcare and breastfeeding facilities at all AOA meetings. • Implementing a new, more flexible, competency-based training programme ‘AOA 21’. • Engaging >150 female medical students/ junior doctors in AOA orthopaedic workshops in 12 months. • Forming an AOA ‘Champions of Change’ working group of male diversity advocates. • Promoting females in orthopaedics through active social media profiles. • Publishing a quarterly newsletter promoting gender diversity and inclusion. >>

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Subspecialty Section

Margaret Fok is currently an Associate Consultant at the Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong, and an Honorary Clinical Assistant Professor of The University of Hong Kong.

From 2007 to 2019, females represented only 16.5% of Australian orthopaedic training applicants; only 12.7% of these females were offered an interview and 12.1% were successful applicants. 20% of female applicants were selected into training, versus 28% of male applicants. A significant gender difference favouring males has been demonstrated in the selection process prior to interview. Fortunately, the interview process for selection during this period shows no evidence of gender bias. Canada: Within the Canadian Orthopaedic Association (COA), females comprise 15.8% of the practicing orthopaedic surgeon membership and 25.8% of trainees. The number of females delivering podium presentations at the COA Annual meeting is in keeping with the proportion of female members in the association34. The COA Gender-Diversity Strategic Plan provides key strategies to advance gender equity35. The focus has been on reducing bias, encouraging females in leadership roles, and facilitating mentorship. A ‘Women in Leadership’ scholarship was introduced to support attendance at a leadership course. Regional sessions are given for university and medical students in an effort to dispel

Philippe Liverneaux is Professor of Orthopedic Surgery and Chairman of Orthopedic and Plastic Surgery in Strasbourg University Hospital. He is past President of the French Society for Hand Surgery, a member of the French Academy of Surgeons and cofounder of the Robotic Assisted MicroSurgery and Endoscopic Society.

Elham Hamdan received her medical degree from the Royal College of Surgeons in Ireland in 1993, and subsequently completed her orthopaedic surgery residency at the University of Toronto in Canada in 2001. She has also completed fellowship training in spine surgery, chronic pain management and sports medicine.

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the myths about an orthopaedic career. Each quarterly publication of the COA highlights a female orthopaedic surgeon to increase awareness of females in Canadian orthopaedics. The COA Annual Meeting has Instructional Course Lectures on implicit bias, leadership and mentorship, as well as burnout and physician wellness. A ‘Mentor for the Day’ programme has been initiated. Moderator guidelines encourage diversity of gender, geography and age across all panels and discourage all-male panels. Breast feeding areas are available. The COA is committed to advocating for gender diversity as well as equity and inclusion for all minorities, both visible and invisible. Expansion of these foundational initiatives are being planned over the coming years35. Chile: Chile has parental leave protected for six months. This can be taken by either parent and is funded by the social security system. Unfortunately, fathers represent less than 1% of the parental leave taken in Chile. Chile also has protected breastfeeding time until the infant turns two years old. In 2019, the first meeting of Chilean female orthopaedic surgeons took place, resulting in the formation of the Association of Female

Subspecialty Section

Orthopaedic Surgeons of Chile. This is focused on: gender equity in the selection process; preventing gender discrimination; establishing a supportive network for female orthopaedic surgeons; and mentoring trainees interested in pursuing a career in orthopaedics.

Violet Lupondo is a senior Orthopaedic and Trauma Surgeon in Tanzania.

Caroline Hing is an Orthopaedic Surgeon and Honorary Reader at St George’s University Hospitals NHS Foundation Trust. She is a member of the BOA Equality and Diversity working group and BOA Education and Careers Committee.

China (Hong Kong): The first female orthopaedic surgeon was appointed to Queen Mary Hospital, Hong Kong, in 1993. As the proportion of female medical students has reached parity, there has been an increase in the number of female orthopaedic trainees to 20%. In Hong Kong, all orthopaedic trainees are employed by the Hospital Authority. There is equal pay and parity of treatment. All female doctors are entitled to maternity leave of up to 14 weeks. On return from parental leave, each hospital is committed to provide a peaceful environment for breastfeeding but no childcare.

70 days old, only the mother is entitled to the parental benefit but after this either parent is entitled to the parental benefit. France: In France over the next 20 years, the medical profession will undergo three major changes: reducing numbers; ageing; and feminisation36. The number of orthopaedic surgeons has risen sharply in 30 years, increasing from 1.44/100,000 inhabitants in 1981 to 4.3 in 2013. Between 2006 and 2019, the proportion of females increased from 3.3 to 7%, and is higher in younger age groups. In 2015, there were 14% females in the 30-34 age group, compared to 0% in the 65-69 age group. In 2019, France had 248 female orthopaedic surgeons. The proportion is significantly higher in hand surgery with 155 females out of 767 members (20%) in 2020, and 63 out of 167 junior members (38%).

“Although diversity strategies may vary between nations, the principles they incorporate hold true for all. Diversity attracts the best talent and leads to improved decision-making and innovation in our organisations.”

There is no part-time surgical training offered by the Hong Kong College of Orthopaedic Surgeons. For those who cannot fulfil the requirements of orthopaedic training due to maternity leave, additional training time is required. Consequently, most female orthopaedic trainees elect to have children after completion of training.

Estonia: During the last five years, 64% of medical graduates have been female. Currently, 36% of orthopaedic trainees are female. The increasing number of female orthopaedic trainees is a reflection of more generous parental leave. One in four orthopaedic surgeons are female and there is no unit without a female orthopaedic surgeon. Female orthopaedic surgeons have been working in Estonian hospitals since the 1950s and the first female orthopaedic head of department was appointed in 1964. The Estonian Orthopaedic Society (EOS) was founded in 1970 and the first secretary general was female. The President of the EOS has been a female since 2015. Maternity leave and pregnancy policies are dictated by national laws. Raising a child is supported through many benefits and it is common to stay at home until the child is at least 18 months old. It is possible to stay at home until the child turns three years without losing health insurance or position of employment. Reduction of workload in the third trimester of pregnancy is commonly accepted. After delivery the parental benefit guarantees the previous income. The parental benefit is paid for a period of 435 days, or until the child is 18 months old. Until the child is

Gulf cooperating countries and Kuwait: Males earned surgical qualifications as early as the 1960s, though it was not until the mid-1980s that women began to receive surgical training37. This has resulted in a gender disparity that persists to the present day. The low participation of females in orthopaedic surgery can be attributed to many issues. Female faculty members make up 10% of Kuwait University’s Department of Surgery. Currently, there are three female orthopaedic surgeons in Kuwait, (data obtained directly from the Kuwait Medical Licensing Department) of which only one is a Kuwaiti national. Between 2014 and 2019, five females have completed orthopaedic training compared to 51 males in Kuwait. Despite the large regional demand for more orthopaedic surgeons, only one female was accepted into orthopaedic residency training in Kuwait for 2020. Prior to that two females were accepted in orthopaedic surgical residencies abroad and since 2014 only one other female has been accepted into the orthopaedic residency programme in Kuwait. Accurate data for Kuwaiti females in residency programmes abroad is not available, (there is no integrated data source indicating the number of surgeons in Kuwait orthopaedic or otherwise, therefore data presented in this section should be viewed as approximate estimates). There is an identified perception that females in the GCC are less likely to match than males in an orthopaedic residency programme. >>

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Subspecialty Section

Poor maternity and parental benefits in Kuwait appear to be a deterrent with the majority of females in orthopaedic surgery residencies in the GCC being single, (data obtained directly from the Ministry of Health). Kosovo: Kosovo is a small country of two million inhabitants, only recently gaining independence in 2008. The orthopaedic surgery department was established in the 1970s. Currently, there are 78 orthopaedic surgeons and 12 trainees. Only three (3.8%) orthopaedic surgeons are female and there are currently no female trainees.

2019 data shows 4.7 % of active registered orthopaedic surgeons are female. Currently, 18% of orthopaedic trainees are female with numbers increasing. Selection processes have been restructured to encourage consideration of diversity as a factor in selecting from candidates who rank equally. However, numbers of females presenting for selection to orthopaedic training remain low. Recent

network for all female registrars and consultants. LIONZ organises introductory workshops for female students led by senior registrars and surgeons, while offering collegiality and mentorship. These have proven popular with students, though it is too early to say whether they will result in influencing career choices.

NZ surveys of medical students and junior doctors suggest that students’ perceptions of orthopaedics, particularly as a career for females, form a considerable barrier38,39.

While the NZOA are committed to improving diversity and representation, challenges arise from having such a small number of female surgeons. Females are represented currently on the NZOA Council and Orthopaedic Training Board and comprise over 20% of RACS Examiners. As we develop a larger cohort of female colleagues, we expect these numbers will increase.

Positive efforts to encourage female junior doctors considering orthopaedics as a career have been undertaken by LIONZ (Ladies in Orthopaedics New Zealand). LIONZ was established in 2017 and acts as a support

Sweden: In Sweden, the number of female orthopaedic surgeons has increased during the last 25 years. There has been an increase from 6% females in 1995 to 17% in 201940. Currently, 35% of residents in orthopaedic

“Leadership in diversity involves engaging female medical students, minimising unconscious bias, mentoring, creating an environment that is inclusive of females and providing support for those with family commitments.�

Currently two of these three female orthopaedic surgeons have leadership positions in the Orthopaedic and Traumatology Society. There is no fixed quota for training female surgeons but, when candidates are considered equal, the female candidate has priority. New Zealand: NZ data reflects striking similarities with other Western nations.

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surgery are female. This increase has been expected in light of the increasing number of female medical students and graduates. 56% of graduates from Swedish medical schools were female in 2018 and of newly accepted medical students in 2019, 55% were female41. Sweden has generous parental leave of 390 days42. Three months are available for each parent, meaning that one parent cannot use all parental leave. This has increased diversity in parental leave and, in 2018, 29% of all parental leave was used by males. United States of America (USA): There were 27,651 board-certified orthopaedic surgeon members in the American Academy of Orthopaedic Surgeons (AAOS), of which 6% were female, in 2019. Of the 3,963 residents in training, 15.4% were female43. Orthopaedic surgery in the USA has been markedly male dominated and gender disparity has persisted, with the percentage of female orthopaedic trainees the lowest in all fields. There are currently less than five female chairs of major orthopaedic departments. There are, however, numerous concurrent efforts in the USA to improve gender diversity: • The AAOS has prioritised diversity within its volunteer structure in its 20192023 Strategic Plan44, including education and transparency in the application and selection process. Implicit bias training is provided. The AAOS was led by its first female president in 2019, and the AAOS Board of Directors will include 25% females in 2020. • The Ruth Jackson Orthopaedic Society was established in 1983 to advance the science and practice of orthopaedic surgery among females. The group prioritises mentoring and professional development of females. • The Perry Initiative was founded in 2009 by a female orthopaedic surgeon and engineers to increase the numbers of females in the field45. • Nth Dimensions was founded in 2004. Their primary mission is to provide resources, expertise, and experience through developing and implementing strategic pipeline initiatives46.

Conclusion Although diversity strategies may vary between nations, the principles they incorporate hold true for all. Diversity attracts the best talent and leads to improved decision-making and innovation in our organisations. Generous parental entitlements and progressive social policies are likely to be drivers for the participation of females in orthopaedic surgery. Leadership in diversity involves engaging female medical students, minimising unconscious bias, mentoring, creating an environment that is inclusive of females and providing support for those with family commitments. Enacting these concepts should result in healthy, fulfilled surgeons, a collaborative and innovative orthopaedic community and ultimately to

better patient care. Most importantly, working towards a fair, equitable and diverse profession is a moral and ethical imperative and, quite simply, the right thing to do. n

Acknowledgements The authors would like to give their thanks to Michelle White for her editorial support in the preparation of this article.

References References can be found online at

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Caroline Hing is an Orthopaedic Surgeon and Honorary Reader at St George’s University Hospitals NHS Foundation Trust. She is a member of the BOA Equality and Diversity Working Group and BOA Education and Careers Committee.

Giles Pattison is a children’s Orthopaedic Surgeon in Coventry and Rugby. He is a member of the SAC and a Regional Surgical Advisor.

Robert Gregory is Lead Clinician in trauma and orthopaedics at County Durham and the Darlington NHS Trust. Robert has an interest in surgical education and is currently chair of the specialist training committee for trauma and orthopaedics and quality management lead in the School of Surgery in the Northern Deanery. He is an examiner at MRCS level and also Regional Specialty College Adviser in trauma and orthopaedics.

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Diversity and inclusion in trauma and orthopaedics at the dawn of a new decade Caroline B Hing, Giles Pattison, Robert Gregory, Fergal Monsell, Justine Clarke, Lisa Hadfield-Law and Deborah Eastwood


rauma and Orthopaedics (T&O) is a challenging yet highly rewarding career. In order to ensure that it continues to attract and retain the best applicants, it is vital that the development of an increasingly diverse workforce at all levels is given priority. This requires acknowledgement that surgeons have other demands on their time, including their families and interests outside their career, this being particularly relevant as those now entering the profession will be expected to work to 67 years and beyond before retiring.

training that number has reduced to 30% and by consultant it is 13%. Whilst it should be acknowledged that the proportion of female surgeons has increased over the past decade (circa 7% across all grades and circa 5% at consultant level) the rate of change is insufficient to match the demographic changes seen in our medical schools (Figure 1 and Table 1). Membership Grade

Female Total

Females in first 5-years of grade




It is well-recognised that a more diverse Locum Consultant 7 3 workforce is associated with improved Post CCT 64 59 performance and increased innovation being one particular benefit. Whilst it is accepted that Table 1: Distribution of females within the first five years post to achieve increased diversity in T&O, many CCT in 2019. groups currently under-represented in the workforce need to be encouraged to BOA Membership: Comparing Gender by Year join, the largest by far is the female 450 0 gender and this 4000 article deals predominantly 350 0 with this group 3000 as an example of the challenges 250 0 we face. Current 2000 figures show that surgery in general 150 0 is not attracting 1000 or retaining a 500 gender-diverse workforce. At the 0 present time 55% 2019 2018 2017 2016 2015 of medical students Female Male No Gender Specified are female but by the time a surgeon Figure 1: Gender distribution showing an improvement from 2015-2019. reaches specialty

Subspecialty Section

T&O is the second largest surgical specialty, however it has the lowest proportion of female surgeons across all grades, with 7% at consultant and specialty and associate specialist (SAS) grades, and 19% at specialty training level1. This suggests that prompt and wide ranging action needs to be taken to address the imbalance and to generate interest in T&O as a career.

Fergal Monsell is a Consultant at Bristol Children’s Hospital where he is involved in the management of limb deformity and trauma. He is Visiting Professor at Cardiff University and Projector at the Grand Academy of Lagado. He has an active clinical and basic science research portfolio and is widely published.

Female Members Total 564 - 2019 Post CCT 6%

Overseas 1% Medical Student 10%

SAS 1%

Retired 1%

Affiliate 13% Foundation Doctor 7%

Honorary 0% Locum Consultant 1%

Consultant 16%

Trainee 44%

The British Orthopaedic Association (BOA) currently has 5,195 Affiliate Foundation Doctor Trainee Consultant Locum Consultant Honorary Medical Student Overseas members, comprising Post CCT SAS Retired 1,955 consultants, 402 Post-certificate Figure 2: Female member distribution across the career grades in 2019. of completion of training (CCT) doctors, 1,183 trainees, 178 foundation doctors The gender disparity has slowly improved over and 198 medical students. In total 11% of the last five years but still shows an underBOA membership is female, with similar representation of women across the career percentages across the grades of the specialty grades. An inclusive surgical profession is one as a whole (Figure 2). that inspires, attracts and retains the best >>








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#BTS2020 JTO | Volume 08 | Issue 01 | March 2020 | | 53

Subspecialty Section

talent from a wide variety of backgrounds. With this aim, orthopaedic associations across the world have started to recognise the strategic importance of actively encouraging diversity2-4.

Justine Clarke is Chief Operating Officer for the BOA.

Lisa Hadfield-Law, RGN MSc, FAcadMEd and education adviser to the BOA.

Deborah Eastwood is UCL Professor of Paediatric Orthopaedic Surgery at Great Ormond Street and the Royal National Orthopaedic Hospitals. Deborah is a former council member of BSCOS (British Society for Children’s Orthopaedic Surgery) and current Board Member for EPOS (European Paediatric Orthopaedic Society).

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The aim of the BOA is to provide national leadership and a unifying focus supporting our members to deliver excellence in patient care. Diversity within the workforce has been shown to improve patient care. This was acknowledged at the 2019 BOA Congress, where a diversity networking event was held as a lunch time session with representation from Council and members. This was primarily a social event designed to gauge the interest of, and to generate support from, the membership and to learn how best to address the need for change. Following the event, a working group was formed to draft a strategic policy document to be taken to Council before dissemination to a wider focus group comprising key stakeholder representatives from women; black and minority ethnic (BAME); disability groups; lesbian, gay, bisexual, transgender and queer (or questioning) and others (LGBTQ+) and the ‘ageing’ surgeon groups. The BOA Council was fully supportive of the draft document with a three-year aim for change. Whilst still in draft phase, the aims include a commitment to understand and define the groups currently under-represented within the BOA; to increase the diversity of the BOA leadership; to promote diversity at Congress and educational events by increasing the diversity of chairs, speakers and invited guests; to increase awareness of trauma and orthopaedics as a career option; and to provide support and maintain interest throughout a T&O career. We are fortunate in being able to attract good quality trainees into T&O but the trend in recent years is for a shrinking ‘appointability gap’ and there is a real danger that in the near future we may have unfilled posts at speciality training (ST) ST3. Other specialties, particularly General Practice, Psychiatry and Acute Medicine are less fortunate and their plight may lead to centrally driven measures to attract trainees to those areas. With such measures our ability to recruit may be put under further pressure.

Maintaining the status quo is not an option if our profession is to thrive. To deliver change there needs to be a willingness to change at all levels of the profession. 2020 heralds the start of a new decade and provides the opportunity to alter the face of the BOA to better reflect its membership and society as a whole, to be seen as a dynamic and empathetic organisation that celebrates and values difference and understands that if successful, this will improve performance and the quality of patient care. n

References 1. NHS Digital. Medical and Dental staff by gender specialty and grade AH2667. Available at: supplementary-information/2019supplementary-information-files/medical-anddental-staff-by-gender-specialty-and-gradeah2667. Accessed January 2020. 2. Emery SE, Carousel Presidents. Diversity in Orthopaedic Surgery: International Perspectives: AOA Critical Issues. J Bone Joint Surg Am. 2019:101(21):e113. 3. MA Day, JM Owens, LS Caldwell. Breaking Barriers: A Brief Overview of Diversity in Orthopaedic Surgery. Iowa Orthop J. 2019;39(1):1-5. 4. Canadian Orthopaedic Association. Gender Diversity Strategic Plan. Available at: https:// COA-Diversity-Stategic-Plan-final-21-2019. pdf. Accessed January 2020.

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Mr Vikas Khanduja Consultant Orthopaedic Surgeon Addenbrooke’s Hospital, Cambridge

Professor Fares Haddad University College Hospital, London, UK

Professor Jean-Yves Jenny University of Strasbourg, France

Mr Fred Picard Consultant Orthopaedic Surgeon Golden Jubilee National Hospital, NHS Scotland

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Subspecialty Section

Women in orthopaedics: the trainee experience Morgan Bailey, Zoe Little, Amy Garner, Roshana Mehdian and Liza Osagie


he proportion of female trainees applying to orthopaedic specialty training at national selection remains low when compared with their male counterparts. These proportions do not reflect those of the graduates leaving medical school. There is no doubt that the number of female orthopaedic trainees has increased over the last few years, and that this is slowly leading to an increase in female orthopaedic consultants.

Morgan Bailey is an ST7 Orthopaedic Registrar on the Wessex Rotation. She was the 2018-19 Women in Surgery Representative for BOTA and BOTA representative on the Women in Surgery Forum at the RCSEng.

Zoe Little is an ST7 in South West London. She is the mother of two girls and is currently on maternity leave.

There are a few theories as to the discrepancy in the number of female orthopaedic trainees, and these can broadly be divided into issues relating to recruitment and retention. Early years experience and exposure to orthopaedics have a significant impact on the recruitment of women to orthopaedics. Factors affecting retention are fairly broad, but there are significant issues relating to

women taking time out of programme either for parental leave, academic or other clinical activities. There are also challenges related to pregnancy and juggling family life with training.

Barriers to recruitment On the whole, female trainees with an enthusiasm for orthopaedics are welcomed into the specialty by their consultant trainers. One of the concerns is the role that other (non orthopaedic) medical professionals play at various stages in the medical student and junior doctor career path. They are frequently guilty of perpetuating the negative orthopaedic stereotype and deterring trainees from an interest in orthopaedics. There exist misconceptions regarding women’s abilities to manage a family alongside a surgical career, often used to dissuade women from pursuing the speciality. Although challenges certainly exist, as detailed later in this article, strategies are being developed to improve trainee experience. There are also unfortunately still those who would cite a woman’s size and strength as a reason not to enter into the career. Another concern is the time devoted to orthopaedic placements in the medical school curriculum. With the absence of significant exposure to the speciality, students rely upon the experience of their other lecturers/clinical supervisors and the unconscious bias that exists in general culture, to form their opinions about orthopaedics as a career. Whilst this limits our recruitment of both male and female trainees, it is certainly a significant contributor to the lack of recruitment of women. There remains a perception amongst some women that they must be better than all of their male counterparts in order to succeed. Whilst striving for excellence is important, one should not need to be better because of one’s gender. This perception is reflected by the phenomenon at national selection that female applicants, although proportionally fewer, perform better and therefore are disproportionately more successful as a group.

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Amy Garner is an ST7 Orthopaedic Registrar on the Kent, Surrey and Sussex Rotation. She is in her final year of a PhD at Imperial College London and is the current joint Dunhill Medical Trust and Royal College of Surgeons of England Clinical Research Fellow.

Pregnancy and parenthood as an orthopaedic trainee Roshana Mehdian is an Orthopaedic Registrar on the South West London Rotation. In 2016, she took two years out of programme working as a British representative for the Department of International Trade at the British Embassy in Washington DC, USA. She has also campaigned extensively on health matters. She has two children under two and works less than full time.

Lisa Osagie is a postdoctoral Specialty Registrar in Orthopaedics on the Royal National Orthopaedic Hospital Rotation, and Senior Lecturer at Portsmouth University. A member of the British Orthopaedic Research Society, Bone Research Society, and the Royal College of Surgeon’s Research Committee; she is the recipient of multiple grants and is continuing active research investigating biological augments to fracture healing.

Pregnancy is a physically and emotionally difficult time for many women - it is unusual to breeze through without any issues, and the demands of working and training in orthopaedics certainly add to this. Even in an uncomplicated pregnancy, symptoms that are often considered to be par for the course (nausea and vomiting, exhaustion, fainting, pelvic girdle pain), can be seriously debilitating, particularly in busy clinics, long operating lists, oncalls and night shifts. Whilst exposure to radiation can be minimised by wearing double lead aprons and standing in an appropriate position far away from the beam, some (but by no means all) trainees will choose to avoid radiation exposure altogether and this must be respected1. The practical demands of operating become even more challenging in the third trimester, when increasing bump size makes it uncomfortable to stand for long periods, to wear lead aprons that fit properly and comfortably, or even impossible to safely reach the operating field. Temporary or sometimes long term adjustments may need to be made to a trainee’s job plan or adaptations to the workplace environment, for example stopping on calls, having a stool available in theatre to allow sitting or perching for longer cases where possible, providing an additional assistant, avoiding operating lists where radiation is essential if that is the trainee’s wish. Early discussion and proactive risk assessment with clinical/educational supervisors and managers should be encouraged so that changes can be facilitated within the department with minimal impact upon clinical activity. Operative numbers and experience attained can suffer during

pregnancy, particularly if long periods of sick leave result, but this can usually be made up in subsequent rotations. It is a common experience that pregnancy whilst working in orthopaedics is not easy, but good support and understanding from supervisors and managers with mutually agreed adaptations do help to smooth the ride. Parenthood, for anyone, is a life changing event. Priorities for parents in orthopaedic training often quickly shift from a heavy emphasis on career to that of carer. Whilst some may still equally prioritise career and carer, others, depending upon their family circumstances or through choice, prioritise their new dependent over career. It is this juncture that is often challenging for a new mother in orthopaedics. Sadly, the orthopaedic culture still has some way to go to see these choices as acceptable and appropriate rather than as a lack of dedication, despite working regulations changing in attempts to level the playing field. Practically this translates to poor attitudes amongst trainers and colleagues around working less than full time which is still considered a nuisance. It can result in a lack of time to read or keep up with extracurricular activities and having to arrive late or leave early for childcare reasons. The lack of flexibility for childcare and special occasions, the length and location of training, and an ongoing mental grapple about priorities and how they are perceived are further difficulties experienced by parents, largely mothers, in orthopaedics. There needs to be a cultural shift towards acceptance that motherhood in surgical trainees does not result from a lack of dedication to one’s career, and that being a mother and successful surgeon - whilst an often challenging combination - do not need to be mutually exclusive. >>

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Subspecialty Section

Out of programme experiences: academia The decision to extend the already lengthy duration of orthopaedic training, for academic or personal reasons, is not one taken lightly. With an ever-increasing need to be competitive, every year a proportion of trainees take time out of programme (OOP) to undertake formal research (OOP-R). In so doing, these trainees are committing to up to three years of additional time to training. Whilst most regard their OOP-R as time well spent: strengthening their Curriculum Vitae, establishing connections within their chosen subspecialty and gaining indepth understanding of research methodology, there are inevitable consequences too. Similarly to consequences faced taking parental leave, these relate to funding, surgical skill maintenance and returning to programme. Funding can be challenging and competitive to secure. Wages may require supplementation with additional on call locums and juggling the two can prove challenging and unpredictable. Having said this, trainees employed under the 2016 junior doctor contract, who return to training having completed an approved higher degree, become eligible for a £4,000 per annum academic premium, in addition to their basic salary, so as not to disadvantage those seeking academic opportunities2. As a craft speciality, many individuals returning to orthopaedic training following an OOP-R

58 | JTO | Volume 08 | Issue 01 | March 2020 |

report feeling deskilled in the operating theatre, or out of practice at managing the pressures of intense on call shifts or busy outpatient clinics3. Recently implemented ‘Return to Training’ (RTT) initiatives recognise this, however, and lay out a series of provisions designed to ease reintegration. For example, during the OOP, trainees are encouraged to participate in ‘Keep in Touch’ days, which may include supernumerary sessions in theatre or clinic, with a dedicated supervisor or mentor4.

current experiences and summarises some of the outstanding barriers that female trainees face. Although some of these issues are not necessarily, on the face of them, unique to women, the reality is that many of them affect female trainees to a greater extent. By identifying and addressing these (sometimes subtle) barriers, orthopaedics as a specialty can ensure that it recruits and retains the best possible trainees, irrespective of gender. n

Academic training can be exceptionally rewarding, but good planning, a carefully selected project and supervisor and a willingness to dedicate time, energy and enthusiasm to the work is essential. The academic environment is very welcoming to women, but they remain underrepresented in the field and the issues discussed may be compounded if the trainee has already been confronted by them for parental reasons. The challenges faced are starting to be recognised with national initiatives to support returning trainees. Half the battle is making trainees and their supervisors aware of the support available to them.

1. Keene RR, Hillard-Sembell DC, Robinson BS, Novicoff WM, Saleh KJ. Occupational hazards to the pregnant orthopaedic surgeon. J Bone Joint Surg Am. 93(23):e1411-5. 2. British Medical Association. Pay scales and guidance for medical academics, 2018. Available at: uk/advice/employment/pay/medicalacademics-pay. Accessed January 2020. 3. Joint Committee on Surgical Training (JCST). Guidance on the management of surgical trainees returning to clinical training after extended leave. Available at: key-documents/return-to-work-guidancefinal.pdf. 4. Joint Committee on Surgical Training (JCST). Out of Programme Research, 2019. Available at: out-of-programme-research/. Accessed January 2020.

Conclusion The number of women in orthopaedic training are on the rise, albeit slowly, and the experiences they have through training are improving. This article gives an overview of


In Memoriam

Alexander Benjamin

1st June 1924 – 16th December 2018 Obituary by Nick Geary


lec Benjamin was a Consultant Orthopaedic and Trauma Surgeon at West Herts Hospitals from 1961 until 1984. Initially, he was on the staff of Watford General and Hemel Hempstead Hospitals, but in the early 80s he moved his sessions from Watford to St Albans, so that all three consultants at Hemel worked together at St Albans. He was born at home in Stoke Newington to Rachel and Joseph Benjamin and soon moved to South Morden. Alec wanted to become a doctor, but his headmaster tried to discourage him as during the war they had no Physics Master. Alec studied for his school certificate on his own, and was admitted to London Hospital Medical School where he trained from 1942 - 1946. He was awarded the Charrington Prize in Practical Anatomy and the Sir Frederick Treves Prize in Clinical Surgery. Student life was split between London and being evacuated to Cambridge. He served in the Home Guard during the blitz. On qualifying, he worked as house physician and surgeon in paediatrics, psychiatry and orthopaedics including two years national service in the RAF. On leaving the RAF in 1949, he alternated between posts in orthopaedics and psychiatry at SHO and registrar level. Having obtained FRCS in 1953, from a Psychiatric Registrar post, he then embarked on a career in orthopaedics. He trained at RNOH, St. Mary’s and was an SR at Charing Cross. In training, he worked for some orthopaedic legends: Sir Reginald WatsonJones, Norman Capener, Carl Nissen.

He was greatly interested in rheumatoid arthritis, publishing widely and contributing to textbooks. He was a founder member of the Rheumatoid Arthritis Surgical Society, serving as secretary. The double osteotomy around the knee bears his eponymous name. Before modern joint replacement surgery, this allowed pain relief and mobility for these disabled patients. He was a founder member of the Cerebral Palsy Society and an early member of the British Orthopaedic Study Group. n

Charles David Richard Lightowler March 1936 – 26th October 2019 Obituary by Richard Pusey


harles David Richard Lightowler – known as David – was born in Leeds in 1936 and was educated at Giggleswick School where he excelled academically and at sport, especially rugby. After National Service, he entered The London Hospital Medical School where he played rugby to county standard. He decided on a career in orthopaedics and stayed at The London for resident and registrar posts gaining his FRCS (Eng) in 1966. In addition he worked in Johannesburg which stimulated his interest in paediatric orthopaedics. He was appointed Consultant Orthopaedic Surgeon to Orsett Hospital in South Essex and also to the new Basildon Hospital when it opened in 1973. His main interests were hip and paediatric surgery and he was a strong Charnley disciple, and was one of the main instigators of hip replacement surgery in the area. He loved teaching and his enthusiasm stimulated a whole generation of junior rotating registrars to take up orthopaedics. He was a strong supporter of the RSM and was President of the Orthopaedic Section and also of the RCS, and after retirement, was Chairman of the Senior Fellows Society. As a colleague he was delightful to work with, but of strong character and was always available for constructive advice, which was given in his brusque no nonsense Yorkshire way! Away from work, shooting and fishing played a big part in his recreational life both in Essex and in Yorkshire and on retirement he moved back to his roots on the river Ure at West Tanfield, where he was able to host friends at the local angling club. He had a powerful bass voice and sang in the choir at Ripon Cathedral. He is survived by his first wife Eileen, and their son and three daughters, two of whom are doctors, and his second wife Margaret. n

JTO | Volume 08 | Issue 01 | March 2020 | | 59

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Leave a lasting legacy Whether you’re someone who is suffering from a musculoskeletal disorder or whether your life’s work is helping those who are suffering; you can really make a difference. Once you have considered your immediate friends and family; please consider leaving a life-changing gift to Joint Action to fund ground-breaking orthopaedic research. Your donations support the BOA Orthopaedic Surgery Research Centre (BOSRC), based at York Trials Unit, which works with the BOA in expanding the number of trials in the UK related to Trauma and Orthopaedics. Your generous donations are helping us to advance Trauma and Orthopaedic research. Thank you very much! Remembering a charity in your Will is simple. For an easy step-by-step guide to everything you need to know about leaving a legacy to Joint Action, please visit

60 | JTO | Volume 08 | Issue 01 | March 2020 |

To book please visit: CONTACT DETAILS:

Email: Phone: 01691 404661

Further information: Jackie Richardson (Course Administrator) Telephone: +44 (0) 1257 256413 Email:, or Mavis Luya (U L Education Manager) Telephone: +44 (0) 1257 256248 Email: Upper Limb Education, Wrightington Hospital WN6 9EP

Websites: (Menu – Education & Events) (Courses)

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