THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 04 / Issue 02 / June 2016 boa.ac.uk
Ozge, Aged 12 at Great Ormond Street Hospital
Inside
Read the News and Updates section for the latest from the BOA and beyond
In our Features section you will find articles that focus on casting standards, fracture clinics and the management of metastatic bone disease
For the latest updates on our clinical issues, see our Peer-Reviewed Articles; the focus of this issue is paediatrics, plus our regular “How I…” piece
News & Updates ––– Pages 02-17
Features ––– Pages 18-43
Peer-Reviewed Articles ––– Pages 44-56
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JTO News and Updates
From the Editor
Contents
Ian Winson, BOA Vice President Is there more said than listened to? So apparently the NHS has managed to wrestle the juniors back to the negotiating table – phew, what a relief! Of course by the time this comes out we may be back to square one or possibly moved on to the consultant contract, but that is part of the fun of being part of an editorial team, trying to anticipate how people might miss the point next time. A recent paper from Manchester describes the much quoted increased death rate over weekends as a statistical artefact. I am fairly sure this will morph into “well, to get the death rates down we need to admit more healthy people over weekends” in the view of the popular press. On a lighter note, in this issue we
focus on our younger patients with Fergal Monsell as Guest Editor. The peer-reviewed section is typified by Fergal’s and Chris Colton’s management of supra condylar fractures essay. The typical thoughtful and cogent arguments show the dignity of keeping clinical scientific argument balanced and patientorientated - something we should all remember. I am sure you will all be pleased to know that our front page illustration is the winner of a competition kindly run on our behalf by Great Ormond Street Hospital and I think has poignancy in these interesting times. Clearly, the topic of Virtual Fracture Clinics is controversial (pages 32 and 36) and deserves comment from our membership. We look forward to hearing your opinions. The article regarding the new format of the instructional course and the realities of CT1-2 training show the progress being made in the educational process and the reality that there is so much more to be achieved (page 26). So, lots to see in this issue. Keep your letters coming - we have peaked at approximately one an issue! Come on! This is your chance to have a rant and know, at the very least; you will be heard but not misquoted!
JTO News and Updates
02–17
18–43
JTO Features
Casting Standards Together The Bone and Joint Decade Global Alliance for Musculoskeletal Health: A Lay Perspective Principles of the BOA Instructional Course – how it works now
New leadership outlines exciting vision for ORUK The Management of Metastatic Bone Disease Fracture Clinic Redesign Legal Aspects of Virtual Fracture Clinics A Time For Change
18 20 24 26 28 30 32 36 42
JTO Peer-Reviewed Articles 44–56
The increasing trend in the surgical management of children’s fractures
44
Supracondylar humeral fractures in children - have we stopped thinking?
48
Management of slipped capital femoral epiphysis (SC FE) - A nationwide drive to develop evidence based care 52
How I Do… a Retrograde Femoral Nailing
56
In Memoriam
58
General information and instructions for authors
60
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JTO News and Updates
Shifting Political Sands Tim Wilton, BOA President
The Spring meeting season has come and largely gone although with scant evidence of Spring thus far! I’ve been delighted to have a chance to see and speak to so many of you at the Specialist Society meetings I’ve visited including BHS and BASK. Both were excellent meetings with a good mixture of scientific and professional activity talks and discussion.
Unfortunately, there were some others, including BSCOS, which I missed as they occurred while I was away on overseas duties, though all the meetings have been attended by a member of the BOA Executive which allows contact and feedback to us from your societies. I will shortly be attending BODS to speak to a gathering of your clinical directors and then a welter of meetings abroad with EFORT and both the American and Canadian Association meetings all in June.
Tim Wilton
A topic seemingly much on peoples’ minds at BASK and BHS was how the information we are getting sent out to us via processes like GIRFT, the NJR, and in the not-so-distant future the other orthopaedic registries, can or should be used to monitor and/or improve our practices. By contrast the overwhelmingly popular topic at AAOS and COMOC appears to be the issue of how it might be possible to prevent one’s income and fees being squeezed beyond tolerance by the many and varied devices people are introducing to cut the overall cost of surgical procedures.
Perhaps we can take comfort in the thought that while we are deeply concerned about both the quality of care for our patients and the level of remuneration that we may receive we may be slightly less obsessed about the latter than some are in other systems. Nevertheless, there is a clear and present link between the remuneration that we obtain, and the attitude towards us on the professional front, and that diminution of our professional standing in general is undoubtedly one of the fundamental issues behind the problems that are reaching such fever-pitch between the government and the junior doctors. That the dispute should have been allowed to reach this dire state of affairs is both a calamity and a damning indictment of the political masters of the NHS. There is clearly a problem on both sides if any such dispute reaches this stage of intransigence and as I write there was an all-out strike last week. I would certainly be strongly in support of an urgent return to meaningful negotiation. However, one has to understand that, whatever has gone on in
previous times, the current generation of junior doctors is the first ever to come through higher education on the basis that they are paying for their own education, and that system was introduced because they are expected to earn more in their careers due to that very education. It is not, therefore, difficult to imagine how our juniors feel if they are informed, some of them barely out of medical school, that they can expect to earn less than they anticipated. Finance is not the only cause of this industrial dispute though and we must urgently address the problems of both structure and organisation in the hospital system, which have lead juniors to feel their training is not being given adequate attention. There will be a different structure to the way hospital practice occurs in the future and there is clear evidence across the world that this is being introduced whether we like it or not. The challenges we must clearly address are therefore how we can maintain, or even improve, training opportunities as well as the quality of care that we
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can offer our patients when we may not have the same sort of infrastructure support upon which we have always relied in the past. Seniors and juniors alike are going to have to get to grips with the changes that are being thrust upon us due to perceptions that the services we provide are unaffordable. The BOA will not stint in our representations to the powers that be to assert that those services are supremely cost-effective. Whether the country can afford our services or not is something politicians and the voters will have to decide. However, since the percentage of GDP spent on health is being reduced and stands to be reduced still more in the next few years, we must resist the arguments that orthopaedics is ‘elective’ and
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can be reasonably withheld from patients by introducing rationing. The recent re-opening of the debate about denying hip and knee replacement to people who are overweight, or who smoke, is a case in point. Few of us would maintain that people should be offered arthroplasty regardless of their weight, BMI or medical condition. Indeed many of us regularly say to our patients that they need to lose weight and offer them assistance in their attempts to do so. That is quite a different thing from saying that they cannot be offered the surgery unless they reach some arbitrary BMI threshold. Interestingly, despite recent public utterances of many involved in commissioning, the
evidence in the literature from the NJR, from Canada and from elsewhere in recent years show that the mortality of overweight and even obese patients is actually lower after lower limb arthroplasty than it is for those of ‘normal’ BMI. It may be true that the morbidly obese may suffer higher rates of certain local complications, but even the quite severely overweight can expect equivalent PROMs improvement compared with those of normal BMI, and are just as likely to be satisfied and pleased with their surgery. If patients’ access to medical services is going to be restricted, and especially if doctors are going to be asked to be complicit in such action, we must surely insist that we have to see clear
medical evidence to support the restrictions. Undoubtedly, we have a professional responsibility to make our patients as fit for surgery as we can before offering them such treatment. If they have done their best, or there is reason to believe they can do little more, surely the responsibility we have is to inform them fully and properly about the risks of the treatments that are still open to them and then help them to make a rational treatment choice? One has to wonder, if they are prepared to target these patients, where the purchasers might be prepared to go next…will they ban surgery for anyone with abnormal LFTs, abnormal renal function or perhaps if they have diabetes, or are on steroid treatment?
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JTO News and Updates
BOA Membership
16% increase in membership
We are pleased to announce that we have had a substantial increase in membership numbers; 681 new members have joined the BOA from the beginning of 2015 to date and we are delighted to welcome many more SAS Surgeons, with a total of 134 currently on this grade.
Specialist Society meetings We have enjoyed catching up with many of our members at the various Specialist Society meetings so far this year. We recently attended BASK and BritSpine, which provided a valuable opportunity to engage with many of you on recent BOA activities and developments across education, training and membership. We will be attending more meetings throughout the rest of 2016, including BOTA, BESS and IOS(UK) and hope to speak to many more of you.
Save the date!
BOA Instructional Course - 7th-8th January 2017
Registration opens early July 2016 www.boa.ac.uk/events/instructional-course
Travelling Fellowship Report: Zimmer Hip and Knee Reconstruction Fellowship 2015
Chloe Scott
I was very grateful to the BOA for awarding me the Zimmer Hip and Knee Reconstruction Travelling Fellowship for 2015. I chose to visit two centres in Boston, Massachusetts. My partner and baby came along too.
Chloe Scott with Dr Harry Rubash
My first visit was to Dr Andreas Gomoll at the Cartilage Repair Centre, Brigham and Women’s Hospital. Dr Gomoll specialises in biological knee reconstruction. During my visit he used both osteochondral allograft, autograft (OATS) and de novo cartilage to manage defects, routinely optimising the mechanical environment of the repair with offloading tibial and femoral osteotomies. The major differences between this and UK practice included the better availability of matched osteochondral allografts, which facilitate large defect management and revisions, and immediate access to MRI. It was invaluable to observe the full scope of joint preserving knee surgery, including unicompartmental arthroplasty, at this specialist centre. The view over the New England Patriots stadium from the operating rooms was an unexpected extra!
Chloe Scott and daughter, Phoebe at Fenway Park
Secondly, I visited Dr Harry Rubash and Dr Andrew Freiberg at Massachusetts General Hospital where the Hip and Knee Reconstruction service runs in conjunction with world renowned arthroplasty research facilities. I was fascinated to visit the Harris Orthopaedics Laboratory, where vitamin E highly cross-linked polyethylene was developed, and the Technology Implementation
Research Centre, where engineers and orthopaedic surgeons collaborate to develop new products using on site mechanical testing labs, wear machines, fluoroscopy labs and finite element modelling expertise. Our visit to Boston was made complete at Fenway Park - a victory for the Red Sox, and for Phoebe, my ten month old, who remained in good spirits for all nine innings!
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JTO News and Updates
Annual Meeting of the British Hip Society 2016 The 30th meeting of the British Hip Society took place on 16th-18th March in St Andrew’s Hall, Norwich, home-city of the President John Nolan. It was attended by 164 members and 161 non-member surgeons, trainees and medical students. Held over two and a half days, the meeting started with three concurrent sessions: The NonArthroplasty Meeting; the Emerging Hip Surgeons Forum and The British Orthopaedic Research Society Meeting. A keynote lecture from Gordon Blunn was then followed by the first Topic in Focus session on Implant Development, Introduction and Development.
Dr Javad Parvizi (right) with BHS President, John Nolan
Over the following two days, 42 podium presentations and 68 posters covering all areas of research were presented. The McKee Prize went to Christopher O’Neill for a randomised controlled study of pelvic positioning during
THR surgery. The BJJ prize was awarded to Nick Frew for a study of antibiotic elution from bone cement. William Reeve received the best poster prize for a study on virtual clinic follow up after hip and knee replacement. There were three further Topics in Focus covering challenges in periprosthetic infection, femoral reconstruction in revision THR and the future of more complex hip surgery: networks and funding. This year’s Presidential Guest Lecture was given by Dr Javad Parvizi from Philadelphia, USA, who gave a comprehensive and extensively researched treatise entitled “VTE Prophylaxis After Total Hip Arthroplasty: Politics, Money or Patient Outcome?”. The meeting concluded with the presidential handover to Professor Fares Haddad. Next year’s meeting will be held at Central Hall in Westminster from 28th February to 3rd March 2017.
BritSpine - Nottingham 2016 Nasir Quraishi and the worldrenowned spinal unit from Nottingham hosted BritSpine 2016. The pre-meeting day was divided between a busy cadaveric workshop and a ‘Spinal Masterclass’ with an interactive discussion format. The main event included 49 paper presentations, with seven papers in a ‘Best of the Best’ section. There were 90 posters as well as a number of unique sessions: Dr Frances Williams delivered the first keynote on behalf of the Society for Back Pain Research on ‘Genetic epidemiology of low back pain’; a symposium on ‘Informed consent in the post-Montgomery era’ with medical and legal experts; a ‘Grandmasters of spine symposium’ with past spinal masters: Alan
Crockard, Steven Eisenstein, Alistair Thompson and John Webb; they shared their wealth of experience and presented cases which had influenced their practice; the first Scoliosis Research Society Worldwide event at a BritSpine conference with PastPresident of the SRS, John Dormans, Daniel Chopin, Ferran Pellisé, Benny Dahl and Hossein Mehdian. The British Scoliosis Society hosted a lively debate on the ‘MAGEC’ system, and an update on the development of British guidelines for dealing with adult spinal deformity. There were a number of politically charged discussions in the ‘Spine Care Strategy 2020’. Allyson Pollock gave a keynote session on ‘Current perspectives in healthcare development.’
A busy exhibition at BritSpine 2016
On the final day, Prof S Rajasekeran reviewed spinal infection with an update on spinal TB. Finally there was a session on spondylolysis with the CMO’s of British Athletics and the England
and Wales Cricket Board, as well as notable spinal experts. The meeting and social events were a tremendous success with excellent feedback.
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BASK - Liverpool 2016 at Royal Liverpool Golf Club. Twenty-eight golfers participated on a cold, windy, but fine day.
Dr Robert Barrack from the USA, presenting the Lorden Trickey lecture
BASK convened in Liverpool on the Albert Dock, Mersey waterfront on 30th and 31st March 2016. This is one of our largest ever Spring meetings and over 400 delegates registered. The meeting was very well supported by exhibiting healthcare companies. On the day prior to the meeting we held our traditional golf competition
This year we joined forces with BOSTAA and ACPA. Each of these societies ran parallel sessions, but also joined the main BASK conference for keynote lectures. Simon Roberts and Deiary Kader organised debate/controversy sessions on sports medicine topics, which proved particularly popular.
from St Louis, Missouri, USA. He gave a masterful address on “Total knee replacement - the patient’s perspective”. The course dinner was held in the magnificent Liverpool Town Hall, one of the finest Georgian buildings in the country. After dinner entertainment was provided by Frank Cognoscenti and his Frank Sinatra tribute band.
Overall, the meeting was a great success and many thanks are due to Hazel Choules, our event organiser, the BASK Executive and the committees of BOSTAA and ACPA. We look forward to an equally successful meeting next year in Southport on 29th/30th March 2017.
This year the emphasis of the meeting was changed in response to feedback at previous meetings. We had fewer free papers and more instructional course lectures. There were sessions on paediatric knee injuries and periprosthetic fractures of the knee. The highlight of the meeting was the Lorden Trickey lecture, this year presented by Robert Barrack
A lively debate between Andy Carr and Ian Corry moderated by Richard Parkinson and Simon Roberts
BOSTAA parallel sessions at the BASK 2016 Annual Spring Meeting
A full BOSTAA session moderated by Deiary Kader and Tim Spalding
The British Orthopaedic Sports Trauma and Arthroscopy Association was formed 20 years ago, but has remained a small association against a background of anatomically-based orthopaedic subspecialty surgery in the UK. We have relaunched over the last couple of years and plan to forge alliances with other organisations, encouraging cross-fertilisation of ideas between for example sports physicians and sports surgeons; surgical techniques for glenoid labral repair and meniscal repair; and the diagnosis and management of tendinopathies and stress fractures. We have held very successful meetings jointly with BASEM, FSEM, RSM and EFOST, but our meeting in March with BASK was BOSTAA’s first in conjunction with another of the BOA’s specialist societies.
The feedback was extremely positive and, in fact, the only complaint was that the room was full and lead to some delegates being turned away from sessions. There were talks on hot topics in sports knee surgery. A highlight was the debate on “The risks outweigh the benefits of knee arthroscopy in middle aged or older”. Andy Carr entered the lions’ den to defend his recent BMJ editorial on arthroscopic surgery of the degenerative knee. Ian Corry, with great eloquence and wit made the case against him. We encourage members of other specialist societies to join BOSTAA if they share an interest in surgery for sports injury. We will look forward to working with all the subspecialties, as well as BASK in the future.
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JTO News and Updates
BSCOS Annual Meeting 2016 the world-renowned National Spinal Injuries Centre (NSIC). The NSIC team described how their approach to prevention and management of complications in children with spinal cord injury has evolved, and can be applied broadly. The highlight of this session was a witty and moving talk by Bradley Adams a patient’s father, who entertainingly and memorably described his family’s experiences with the clinicians treating his son.
Dan Perry being awarded the Orthopediatrics Fellowship by its Chief Medical Officer, Peter Armstrong
The British Society for Children’s Orthopaedic Surgery annual meeting moved to the beautiful Buckinghamshire countryside. Hosted by Jo Hicks from Stoke
Mandeville, the two day meeting was held at Horwood House. Its themes reflect the unique position of Stoke Mandeville as a District General Hospital, which contains
The orthotics seminar explored how commonly used orthoses work. Professor Jim Wright presented a comprehensive summary of the sometimes patchy evidence supporting popular orthotic interventions, reminding us that we could do better. Our final session examined how paediatric orthopaedic
services have evolved in the UK, and the ad hoc way that the caseload is distributed between specialist centres and district general hospitals. We heard from tertiary centres, DGH’s and even a commissioner. Simon Barker presented the results of a survey of BSCOS members which highlighted the breadth of views as to the viability of small practices. The discussion which followed was thoughtful and enthusiastic. Some high quality scientific papers were presented, and updates on registries and educational podcasts reflected the huge amount of work going on behind the scenes at BSCOS. Huge thanks to all who attended and supported this year. David Rowland will host next year’s meeting on 9th-10th March at the sumptuous Grand Central Hotel in Glasgow.
BLRS Annual Meeting 2016 The British Limb Reconstruction Society 2016 was held at the majestic Titanic Hotel, in the Stanley Docks, Liverpool. In his welcoming address, organising host Leroy James left us in no doubt about the historical importance of Liverpool. The venue’s historical links with international trade routes was poignant as the meeting was truly international, with speakers from South Africa, India, Republic of Ireland, Germany, France and the UK. Konrad Mader from Hamburg lectured on the management of elbow stiffness. Dr Nando Ferriera, from South Africa, presented the results of distraction to treat stiff tibial non-unions and the management of severe tibial plateau fractures.
He was joined by a couple of fellow Springboks. Dr Birkholz talked about the principles of correction of foot deformity. Dr Ampie Viljoen, a vet, is easily the most experienced wildlife Ilizarov surgeon in the world. His case studies were fascinating and a welcome exposé of the difficulties in treating quadrupeds. BLRS 2016 was notable as it was the first joint meeting with British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). My personal highlights of the joint day included Prof Dr Thierry Bégué sharing his experience of the Masquelet technique, an invaluable means of salvaging limbs with soft tissue and
(L-R) Speakers - Konrad Mader and Dr Rajasabapathy with BLRS President Selvadurai Nayagam and local host Badri Narayan
bone loss. Dr Sabapathy from Ganga Medical Centre, India discussed his vast experience in the management of compound fractures. His clear vision has
helped create the Ganga Hospital Score, a lasting legacy, which enforces the principles of limb salvage for frame surgeons the world over.
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JTO News and Updates
BOA Latest News BOA National Clinical Leaders Programme
Applications are open for the BOA Clinical Leaders Programme 2016/17. The programme provides an excellent opportunity for fellows to develop leadership potential within the trauma and orthopaedic field. The programme is open to newly appointed consultants, senior trainees, senior SAS doctors and post CCT fellows. Candidates can apply for the programme individually or through their Trust. In addition, this year a selection of BOA Specialist Societies are sponsoring fellows on the programme who have an interest in their given speciality. Details about the programme, its application process and access to the online application form can be found at www.boa.ac.uk/trainingeducation/boa-national-clinical-leaders-fellowships-programme. Deadline for applications – 5th June 2016.
Junior Doctor Contract Negotiations The proposed new contract for junior doctors still threatens to be imposed on 1st August. The BOA deplores the government’s decision to impose a contract on junior doctors. We are strongly of the view that negotiations should be resumed as a matter of urgency to arrive at an expeditious and mutually agreed outcome. As matters currently stand there is a serious risk that many demoralised junior doctors will choose to leave the NHS in England. As a consequence the country could potentially lose a generation of hard won expertise that will be essential to the future care and wellbeing of patients. In the longer term, a view that the BOA espouses as being of particular importance, we stand in real danger of losing the best and brightest minds from engaging in a career in medicine. This would have devastating repercussions for the tens of thousands of people suffering from orthopaedic trauma and longer term orthopaedic conditions. For further information on the junior doctor contract please visit www.bma.org.uk/working-forchange/junior-and-consultant-contract-home and view the GMC’s guidance at http://bit.ly/1WkiquB.
NHS Right Care Programme NHS Right Care is a programme designed to increase value in healthcare by reducing unwarranted variation. The programme uses the NHS Atlas of Variation and Commissioning for Value Packs to enable commissioners to compare, for example, hip and knee replacement rates to their peers. Following this comparison, Right Care supports commissioners to work with local clinicians and managers to establish whether variation is unwarranted and, if so, develop a plan to reduce the unwarranted variation. The Right Care Programme is expanding rapidly, and we are keen to hear feedback on Right Care from members.
PHIN (Private Healthcare Information Network) Readers may recall that PHIN (Private Healthcare Information Network) has been tasked with implementing a series of CMA (Competition and Market Authority) remedies to increase transparency in privately funded healthcare. PHIN is currently working with all hospitals that treat private patients to collect the necessary data. Shortly, all consultants who practice privately should hear more about PHIN, including how the changes will impact them and the process for consultants to check their own data prior to publication. In the meantime, there is some background information available at https://portal.phin.org.uk/pages/Consultants.html.
T&O emerging registries The BOA Quality Outcomes Programme is continuing to support nine emerging T&O registries in their growth and development. The BOA and registries have discussed a future development of this programme in which the BOA could provide support to offset the significant burden on clinicians running these registries and promote a harmonised or common approach between these where appropriate. This concept, known as the Trauma and Orthopaedic Registries Unifying Structure (TORUS), is currently in active development with the registries and we will continue to keep stakeholders updated, particularly in relation to funding and agreement on a number of key operating principles.
Outcome Publication for 2015/16 The details for the Outcome Publication programme for this year are currently been finalised. We will be in contact with members soon with more information. Please look out for communications from ourselves and the NJR regarding this if you are a consultant undertaking joint replacements in England.
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NJR Data Quality Audit The NJR’s major data quality audit has been taking place since last summer; the majority of NHS hospitals have participated and this has proved a valuable process for both the NJR and Trusts. The NJR is now commencing a second round of the process and the BOA would strongly encourage all units to take part, especially those that did not get involved previously. For more information about the first round, visit http://tinyurl.com/NJRDQ.
BOA Commissioning Guide Review The BOA is continuing to review four of its NICEaccredited Commissioning Guides. These Guides set out evidence based high value care pathways for: • Painful Osteoarthritis of the Knee • Painful Tingling Fingers • Painful Deformed Great Toe • Pain arising from the Hip in Adults The revised guides will be subject to public consultation. All BOA members will be alerted when the consultation opens.
Royal College of Surgeons continues to stand against rationing In April, the Royal College of Surgeons of England criticised Procedure of Lower Clinical Value policies, proposed by six Birmingham CCGs, on the grounds that certain elements of the policies would create “barriers to clinically necessary treatment”. The policies would mean that patients with a Body Mass Index of 35 or greater would not be granted access to Hip or Knee Replacement, except via individual funding request in cases of “exceptional clinical need”. The College called on the CCGs to rethink this approach. The College letter, on advice from the BOA, also challenged the decision to list Hip and Knee replacement as Procedures of Lower Clinical Value given the highly cost effective nature of the procedures. The RCS letter was widely covered in national and local press, including The Telegraph and The Health Service Journal. The BOA expects discussion about rationing of surgery and access to treatment to continue.
The 3 Peaks Race Jon Smith, an orthopaedic consultant from Leeds, took part in the Yorkshire 3 Peaks Race to raise money for Joint Action. He completed the race in 3 hours, 51 minutes on 30th April. Even though the conditions were tough with plenty of snow coverage on high ground, Jon impressively finished in 129th position from over 1,000 runners. Jon has raised nearly £700 for Trauma and Orthopaedic research. Thank you, Jon.
The London Marathon 2016 We would like to say a big thank you to consultant, Pete Lewis; post CCT, Veronica Roberts (and her husband, Steve Powell); trainee, David Ferguson; past President David Jones’ daughter Clare O’Shea and her husband James; and Adrian Stevens who has been directly affected by the fantastic work you do. This amazing team ran the Virgin Money London Marathon on Sunday 24th April, raising money for Joint Action (the Orthopaedic Research Appeal of the BOA). Adrian, in particular, would be in a wheelchair now were it not for the orthopaedic team at his local hospital. We have a limited number of Golden Bond places for the 2017 Marathon. Submit your interest for a guaranteed place with Joint Action by emailing jointaction@boa.ac.uk.
(L-R) James and Clare O’Shea and David Ferguson with his Dad – sporting their well-deserved medals
For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.
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JTO News and Updates
BOA Annual Congress 2016 13th-16th September, Belfast Waterfront congress.boa.ac.uk #BOAAC
The BOA Congress 2016 Guest Lecturers include: President’s Guest Lecture Professor James Wright Paediatric Orthopaedic Surgeon and renowned scientist
Robert Jones Lecture Joe Dias Professor in Hand and Orthopaedic Surgery and Head of the Academic Team of Orthopaedic Surgery at the University Hospitals of Leicester
Against the backdrop of the theme, ‘Clinical Leadership and Engagement’, we are delighted to present a diverse and innovative programme which will focus on a wide variety of broader professional issues, plenary lectures and revalidation sessions. The sessions are designed to centre on key updates, inventive ways of working and to share best practice. We have a range of high profile speakers from government, stakeholders and professional bodies focussing on contemporary and topical issues.
Broader Professional Issues This year we will be running specific sessions on GIRFT – a look at the progress to date, case studies and troubleshooting advice; Commissioning – exploring the key challenges and priorities in the current health landscape; and Coding and Tariff – focussing on the emerging issues and developments affecting Coding and Tariff. Other sessions will focus on Duty of Candour and Consent.
Revalidation Sessions We have an exciting range of revalidation sessions throughout the Congress to suit all. These sessions will include key updates and current issues. We are delighted to confirm that there will be all day Trauma and Spine revalidation sessions.
Awards and Prizes Once again, we will be showcasing the ‘Best of the Best’, bringing together the winners for the best paper award from each region in the UK, to compete for a national award. We also have a brand new Student Paper Prize this year, as well as the Simulation Award, BOA Clinical Leaders Programme Poster Prize and the BOA Young Investigator Prize. In addition to all the above, we are pleased to announce that we will also be running further sessions including leadership for clinical directors, the introduction of new implants and a session dedicated to SAS surgeons.
Howard Steel Lecture Mandy Hickson A former Royal Air Force pilot
Travelling to Belfast The 2016 Congress will be taking place at the Belfast Waterfront, which is conveniently located within a 10 minute walk of the city centre. Travelling to Belfast could not be easier. There are two airports and a taxi from George Best City Airport takes around 15 minutes and 45 minutes from Belfast International Airport. There are sea crossings from Scotland and England and a direct rail link from Dublin. Book your travel now for the best available rates – visit the BOA Congress website for further details and to plan your route: congress.boa.ac.uk/travel. You can book your hotel through Visit Belfast, please view the accommodation page on the Congress website. We hope that you will join us in Belfast to discuss and share best practice in what will be an informative and compelling four days. Visit congress.boa.ac.uk for further details.
FREE* BOA member Congress registration is now open until Wednesday 1st June.
(*Terms and Conditions apply). Non-member registration will open on 1st June. Register online at congress.boa.ac.uk
Volume 04 / Issue 02 / June 2016
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Page 13
The 2016 Robert Jones Golf Tournament The Robert Jones Cup has an interesting history. The competition was first proposed by Thomas Porter McMurray (BOA President 1940-1942) in 1936 to be held at the spring meeting the following year. Even though McMurray was based at Liverpool he was actually born and studied in Belfast – the location of this year’s Annual Congress. After the war, the golf became a regular annual competition at the autumn meeting for the Robert Jones Cup. According to the ‘History of the BOA: the first 75 years’ book; the distraction from the scientific sessions somehow seems in keeping with the earliest traditions of the Association.
The cup had been presented by Rowley Bristow (BOA President 1936-1937) ‘to promote sport and fellowship among members of the Association’. A replica costing £25 in 1967 was presented to the winner. The executive committee thought that this charge should be met by those competing and a fee of ten shillings (50p in today’s money) was imposed the following year. The BOA Robert Jones Golf Tournament will take place the afternoon of Monday 12th September at the Royal Belfast Golf Club – home to the oldest golf course in Ireland – and will be hosted by Ian Corry. Places for the golf outing are limited, please book your place early at www.boa.ac.uk/theboa-robert-jones-golf-tournament.
JTO Caption Competition Starting in this issue and every issue going forward, we will be including a caption competition where you can win a prize for the best caption. We would also encourage you to send photos into us for future issues whether they are taken at conferences, meetings or at work. Enter the competition and also send photos to jto@boa.ac.uk with the subject: Caption Competition.
British Orthopaedic Specialists Association Following the success of the meeting at the BOA Congress last year; BOSA is more active than ever. We ask that all SAS surgeons who are BOA members recommend to their colleagues to join BOSA and the BOA. BOSA are holding a combined course with the Royal National Orthopaedic Hospital on 27th-28th June 2016. The course will be an overview of current clinical concepts covering: Tumours, Arthroplasty, Spine, Nerve Injury, UL and LL pathology and Paediatric Orthopaedics. You can find further detail at www.rnoh.nhs.uk/health-professionals/courses-conferences/ bosarnoh-current-concepts-clinical-practice-for-sas-doctors.
To start you off, here is the first photo. Please submit your caption by 8th July 2016. BOSA at the BOA Congress 2015
Volume 04 / Issue 02 / June 2016
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JTO News and Updates
International Paediatric Orthopaedic Symposium Pranai Buddhdev, ST6 The 12th Annual IPOS Meeting was held at the World Disney Swan Resort in Orlando, Florida from December 8th-12th 2015. With 440 delegates representing 22 countries, this POSNA-
organised symposium boasted an outstanding international faculty debating current concepts and leadingedge issues in the field of paediatric and adolescent orthopaedics.
The format allowed attendees to customise their learning experience according to their practice needs, with choices from over forty breakout sessions including hands-on technical workshops, demonstrations and industrysponsored satellite sessions. Seminal lectures covered a spectrum of pathologies, authors’ preferred techniques and an insight into peak performance. An emphasis on case-based discussions and a live mobile app-based e-moderator service encouraged audience participation and interaction. Principally focused on trainees, the inaugural session included topics such as ‘resident career planning’, ‘work/life balance’ and ‘making the most of your fellowship’. The ‘Cases & Cocktails’ session provided a unique opportunity to
The Original. Made in Germany.
discuss cases and network with some of the leading surgeons and researchers in the field in a relaxed environment. The most popular attraction however, was the TOP GUN Competition, a timed motorskills accuracy contest assessing fundamental techniques related to paediatric orthopaedics including Ponseti casting, SCFE pinning, arthroscopic knot tying and pedicle screw placement. As a UK trainee, I was in awe of the educational quality and networking opportunities offered by IPOS, and would encourage more paediatrically-inclined colleagues to attend. This year’s IPOS will be held 6th-10th December 2016. Full tuition scholarships (value $1,149) are available through competition for residents (registrars) and fellows, via the IPOS website (ipos.posna.org).
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Volume 04 / Issue 02 / June 2016
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Page 15
Cast Life: A Parent’s Guide to DDH: Developmental Dysplasia of the Hip Explained - Natalie Trice Publishers: Nell James £9.99 Review by Fergal Monsell We spend our professional lives studying conditions we encounter from a detached, clinical perspective. It is therefore instructive and refreshing to read this elegant account of the process surrounding the diagnosis and management of developmental dysplasia of the hip (DDH) from a patient and parent’s point of view. This book is written as a guide for the parents of a child with DDH. Its purpose is to make sense of the complex medical process. It is thoughtfully constructed, considers each stage of the journey from diagnosis through non-surgical and surgical treatment. It translates
complex medical information into straightforward prose and deals with the practicalities of each stage of management. There are numerous tips that are the product of the author’s experience and insight including a detailed description of how to manage a child in a hip spica. There is an excellent account of the wider implications for family members, including the emotional consequences, which are omitted from the majority of clinical accounts of this condition. The author uses a variety of styles, but perhaps the most useful are
quotations from parents, which punctuate each chapter. Additionally, there are case studies which illustrate the reality of treatment. These case studies highlight that the views are not just the sole opinion of the author, but a consensus of parental experts. Although written for a non-clinical audience, I strongly recommend this book to any professional involved in the treatment of
DDH. It provides a rare insight into the consequences of the management decisions we make.
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JTO News and Updates
Wisepress Book Review BOOK OF THE QUARTER
NOW AVAILABLE
Paediatric Orthopaedics: A System of Decision-Making
Foot and Ankle Disorders
Author/s: Joseph, B; Nayagam, S; Loder, R T; Torode, I ISBN: 9781498708401 Publication Date: 14th March 2016 Price: £127.00 Featuring a practical focus, Paediatric Orthopaedics: A System of DecisionMaking provides a guide to managing a wide spectrum of orthopaedic conditions in children. The book provides strategies for determining an optimum management approach to follow in any given situation, thus empowering surgeons to adapt their approach to the needs of individual patients.
Paediatric Orthopaedics in Clinical Practice
Author/s: Jung, H ISBN: 9783642544927 Publication Date: 6th March 2016 Price: £112.00
Author/s: Aresti, N A; Ramachandran, M; Paterson, M; Barry, M ISBN: 9781447167679 Publication Date: 21st March 2016 Price: £37.99
Operative Techniques in Spine Surgery
Netter’s Concise Orthopedic Anatomy
Author/s: Rhee, J; Boden, S D; Wiesel, S W ISBN: 9781451193152 Publication Date: 25th March 2016 Price: £178.00
Author/s: Thompson, J C ISBN: 9780323429702
Publication Date: 14th March 2016 Price: £40.99
CONFERENCE LISTING: Organisation
Conference/meeting
EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org
1-3 June 2016, Geneva
WOC (World Orthopaedic Concern) www.wocuk.org
4 June 2016, Sutton Coldfield
CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org
8-11 June 2016, Japan
BOTA (British Orthopaedic Trainees Association) www.bota.org.uk
16-19 June 2016, Hinckley
BESS (British Elbow and Shoulder Society) www.bess.org.uk
22-24 June 2016, Dublin
IOS (UK) (Indian Orthopaedic Society (UK)) www.indianorthopaedicsociety.org.uk
8-9 July 2016, Leicester
BORS (British Orthopaedic Research Society) www.borsoc.org.uk
5-6 September 2016, Glasgow
BOA (British Orthopaedic Association) www.boa.ac.uk
13-16 September 2016, Belfast
BSS (British Scoliosis Society) www.britscoliosissoc.org.uk
13-14 October 2016, Middlesbrough
BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk
13-14 October 2016, Cardiff
BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk
2-4 November 2016, Bristol
SBPR (Society for Back Pain Research) www.sbpr.info
3-4 November 2016, Preston
BTS (British Trauma Society) www.bts-org.co.uk
9-10 November 2016, Birmingham
OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk
12-13 January 2017, Coventry
BHS (British Hip Society) www.britishhipsociety.com
1-3 March 2017, London
BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk
9-10 March 2017, Glasgow
BLRS (British Limb Reconstruction Society) www.blrs.org.uk
23-24 March 2017, Leeds
BASK (British Association for Surgery of the Knee) www.baskonline.com
28-29 March 2017, Southport
Navigating the Challenges of Osteoporotic and Pathologic Fracture Repair Osteoporotic Fractures
Pathologic Fractures Clavicle
9 million annually
Fractures Due to Osteoporosis1
Olecranon
25,000 per day
Ulna
One fracture every 3 seconds
1 in 2 women and 1 in 4 men
Costs Due to Osteoporotic Fractures4
50
65 age
Pathologic fractures ~50% are frequent with bone metastases, developing in up to 30 percent of patients.8
Due to compromised bone and age, a steady increase in fractures occurs from age 65 for both genders3
fracture incidence
over age 50 will develop an osteoporotic fracture in their lifetime2
80
1.2 million new cancer cases are diagnosed each year. Approximately 50% NEW CANCER of these tumors can METASTISIS TO SKELETON spread (metastasize) to the skeleton.7
Radius Metacarpal
>€32 Billion in E.U. (Direct health care expenditures)
>$20 Billion in U.S.
Indirect costs (e.g., lost productivity for patients and caregivers) likely adds billions of dollars to fracture care costs5
Fibula
= IlluminOss CE approved indications
Osteoporosis is the most common cause for fractures in the elderly.6 Common osteoporotic fracture sites are the forearm, humerus, ankle, pelvis, and spine.9
Fracture Repair Treatment Challenges Achieving stable fixation or adequate purchase in poor quality bone remains a technical challenge in fracture repair surgery.9 Elderly fracture patients may also have reduced muscular and bone mass and increased bone fragility and structural modifications such as medullary expansion.9
Advancing fracture fixation through minimally invasive, conforming, intramedullary implants Enables a minimally invasive surgical approach10,11 Conforms to the intramedullary canal10,12,13 Delivers rapid longitudinal and rotational stability10,11,12,13 Accommodates the use of ancillary fixation devices along the length of the implant10,11,12,13
The IlluminOss solution delivers a completely new approach to fracture repair which® may promote patients’ return to mobility and activities of daily living.
Visit us at EFORT 2016, Booth A4-01 To learn more about fracture repair using IlluminOss or to see videos of the IlluminOss procedure please visit http://www.illuminoss.com/ This product has the CE mark and is available for sale in the EU.
REFERENCES:
9
1
http://www.iofbonehealth.org/facts-statistics#category-14
2
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781233/
10 Heck S, Gick S, Rabiner R, Penning D, New Strategy in Geriatric Traumatology – First use of an intramedullary photodynamic polymer in the humerus. VSOU Baden-Baden (South German Orthopedic Congress). April 28-May 1, 2012.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781233/
3
J Bone Joint Surg Br. 1998 Mar; 80(2):243-8. Epidemiology of fractures in 15,000 adults; The Influence of Age and Gender http://capturethefracture.org/health-economics
4
http://www.capture-the-fracture.org/health-economics
5
http://www.ncbi.nlm.nih.gov/books/NBK45502/
6
http://www.niams.nih.gov/health_info/Osteoporosis/default.asp
7
http://orthoinfo.aaos.org/topic.cfm?topic=a00093
8
http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-0142(19971015)80:8%2B%3C1628::AID-CNCR13%3E3.0.CO;2-1/full
11 Vegt PA, Muir JM, Block JE. The Photodynamic Bone Stabilization System: a minimally invasive, percutaneous intramedullary polymeric osteosynthesis for simple and complex long bone fractures. Medical Devices: Evidence ad Research. 2014; 7:453-461 12 Heck S, Gick S, Penning D, Intramedullary polymer implant with angular stability for minimally invasive repair of pathologic fractures. Meeting of the Associations of Surgeons – Cologne, Germany. 13 Heck S, Gick S, Penning D, Minimally invasive stabilization of upper limb pathological fractures with an intramedullary polymer. AAOS (American Academy of Orthopedic Surgeons). New Orleans, March 11-15, 2014
900504.A
Volume 04 / Issue 02 / June 2016
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JTO Features
Casting Standards Sue Miles
The measurement of care quality against agreed standards has become a fundamental part of healthcare (Francis report 2013)1. Clinical audit is at the heart of clinical governance.
We are pleased to announce that new Casting Standards are available on the BOA website and a hard copy will shortly be available in every casting room around the UK. These standards expand upon the initial document, A Framework for Casting Standards (2000). It was compiled by members of the Society of Orthopaedic and Trauma Nursing and the BOA Casting Committee and was published by Royal College of Nursing2 in November 2015.
(BCC)3 is now a joint award with Glasgow Caledonian University. It takes a minimum of 20 months for candidates to complete the training. Although most casting rooms have at least one person with the BCC qualification, it is still possible for unsupervised, nonqualified persons to apply casts to patients. This is in contrast to the BOA Patient Liaison Committee recommendations that they expect casts to be applied by a BCC holder.
There are seven standards covering; staff qualifications, health and safety, communication and documentation, cast application, cast removal and adaptation, patient education and finally personal professional development.
The BOA holds a register of BCC holders, who are asked to maintain CPD and pay a small fee every three years. Their status can be checked by emailing recert@boa.ac.uk. The Casting Standards audit tool should highlight areas where qualification levels fall short of the recommendations, and provide the necessary evidence to enable service improvement.
The format includes an audit protocol, which should enable practitioners and managers to assess and monitor how the level of care in their department matches up to the standards. We hope this will enable staff to implement change and improve care for patients undergoing cast treatment.
Sue Miles
It is frustrating that the education for casting personnel, which the BOA instigated in 1982, is still not recognised by the NHS. The British Casting Certificate
I would ask you to support your orthopaedic practitioners working in casting; they are a comparatively small group who work extremely hard at a high skill level on the lower pay bands. Please help us ensure casting standards are maintained and audited to ensure your patients receive the best care.
British Orthopaedic Association Casting Committee, 2015, Casting Standards, available online at: www.boa.ac.uk/events/ casting-standards. n Sue Miles has instigated and has run the BOA casting courses and examinations since their instigation in 1982, and has been the National Casting Training Advisor for the BOA since 1998. She works as an independent Casting nurse specialist applying casts to patients. Sue received the BOA Presidential Merit Award in 2013.
References 1. Francis, R, 2013, Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, Available online at: www. midstaffspublicinquiry.com/sites/ default/files/report/Executive%20 summary.pdf 2. Royal College of Nursing (RCN) Society of Orthopaedic Nursing, 2000, A Framework for Casting Standards, RCN publishing Company, Harrow, Middlesex 3. British Orthopaedic Association, British Casting Certificate Courses, details available online at: www.boa. ac.uk/events/musculoskeletalcasting-and-splinting-courses
Volume 04 / Issue 02 / June 2016
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JTO Features
Together Alistair Stirling
Lessons learnt from annual multidisciplinary meetings to implement a previous NICE guideline have potential wider application to other clinical arenas. In 2005, after 15 years working as a consultant spinal surgeon with an interest in spinal oncology, I was approached to contribute to the proposed NICE guideline on metastatic spinal cord compression (MSCC). I was pleased to be appointed as lead clinician, with Barrie White as Chairman. After an initial scoping exercise, advertisement and appointments, the Guideline Development Group (GDG) was appointed (see Table 1). Chair - spinal neurosurgeon Clinical lead - orthopaedic spinal surgeon Oncologists - three DGH spinal surgeon Radiologist DGH physician General practitioner Patient Carer Specialist nurse Radiographer Rehabilitation physician Palliative care physician Physiotherapist Occupational therapist Public Health clinician Alistair Stirling
Table 1: The composition of the GDG
At our first meeting Fergus Macbeth, a Consultant Oncologist, explained the guideline development process. We completed an initial exercise – somewhat dismally! Fergus correctly concluded that the first two meetings should be spent educating the GDG on the process. This was very beneficial. Following this, the group got down to work under Barrie’s tireless chairmanship. The medical members became aware of the depth of knowledge that the allied health professionals brought to much of the process. Debate was usually good natured, but often hard fought. We had to acknowledge that the evidence was often sparse and compromise was required to reach a consensus. The first GDG meeting took place on 19 September 2006. Two years later, after 20 meetings, we had distilled a 10ft column of paper to about 200 references and a 207-page document. This contained 108 recommendations (NICE version) with 10 key priorities (Quick Reference Guide) and several research recommendations. The 136 registered stakeholders, submitted 367 comments which
were all answered individually by the chair and lead clinician assisted by the cancer collaborating centre staff in an intense two day session. Surprisingly all deadlines were met. There were many highpoints. The National Collaborating Centre for Cancer (NCCC) team was faultless. The GDG was excellent, colleagues all attended and contributed. They were supportive throughout the consultation and its publication. There were also significant challenges. It is difficult to navigate a path to a somewhat unknown end product, and it is frustrating how poor the evidence is. Nevertheless, the eventual publication on 26 November 2008 was very satisfying. 2009
NICE MSCC Guideline CG 75
2010
Acute Oncology Measures development
2011
Implementing Acute Oncology Measures
2012
“After Wards” Allied Health professionals role
2013
• NICE MSCC Quality
Standard QS56 commentary on proposals • NHSE Service Specification D14 2014
• NICE MSCC
Quality Standard QS56 implementation • Service improvement proposals 2015
Data, AOM update, Instability and Orthoses NICE review Survey
Table 2: The themes of the annual implementation meetings.
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These included: 1) Data and audit which for MSCC included the Royal College of Radiologists audit of those receiving radiotherapy, HES data and the British Spine Registry data for those treated surgically; 2) Updates from peer review including NHS Quality Surveillance; 3) A commissioner’s presentation on anticipated changes in commissioning. There is also an annual clinical topic review and focus on a clinical service (Table 3). More recently, a slot for topical issues has proved popular.
Figure 1: Allied Health Professionals attendance
In the afternoon there are hour long workshops run by invited faculty who edit the conclusions and prepare a five-minute summary presented after Tea. These include: • Clinical decision-making in MSCC run by experienced oncologists and surgeons with illustrative cases; • Data and audits with input from
Figure 2: Medical attendance
Following publication there was a gradual, dawning realisation that publication would achieve little without an implementation process. The National Cancer Action Team (NCAT) was asked to fund an implementation meeting. They were supportive, if unclear where funding might come from. Approximately a year after the guideline launch, the first meeting took place. Cancer networks (although now defunct) were useful to heighten awareness
of and maintain attendance at the meetings. The meetings were set up to reproduce the composition of the GDG. The attendance over the years is shown in Figures 1 and 2. For the first meeting the content was to some degree experimental, but after this we had an annual meeting theme (Table 2). These were based upon current developments. There were also recurring topics for discussion.
bodies such as the RCR, the British Spine Registry and NCIN. We are trying to achieve synthesis to understand variation to drive clinical improvement; • Commissioning and networks; • The clinical service presented in the plenary session and how that service might be best involved in optimising care for these patients; • Clinical Guidance update review and implementation. These come around very fast but unless implemented are meaningless. Meetings conclude with discussion of what is going to be relevant for the following year. Many of the delegates have supported the meeting year after year and feedback has generally been excellent, sufficient even to have maintained the funding stream despite the current financial climate. To date it has not been necessary to seek industry support, although, in the future this >> may become a consideration.
Year
Clinical topic focus
2009
Oncology overview
2010
Cancer of unknown origin
Interventional Radiology Vertebroplasty vs MIS Surgery
2011
Breast
Spinal Cord Injury Specialists (BASCIS)
2012
Prostate
Physiotherapy, Occupational Therapy
2013
Myeloma
Pain clinic and Palliative care
2014
Uncommon / Isolated metastasis
Psychology, Diagnostic Radiology update, Beam therapies vs Surgical excision for isolated metastases
2015
Melanoma
Instability and Orthoses
Table 3: Topics reviewed annually
Clinical service
Volume 04 / Issue 02 / June 2016
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JTO Features
IF YOU WANT TO TRAVEL FAST – TRAVEL ALONE; IF YOU WANT TO TRAVEL FAR – TRAVEL TOGETHER.
So, why have I written this article? For two reasons: firstly as surgeons we often have tunnel vision. It is important to look outside our sphere. For example, Nick Peirce from the England and Wales Cricket Board, and Robin Chakraverty from British Athletics, showed us at a recent Britspine meeting how elite athletes are usually able to settle their painful spondylolysis non-surgically. We can learn from differing groups and their experience. Secondly, in 2009, the NICE guideline on low back pain was published. Unfortunately, there was a poor level of uptake. This may, in part, have been due to the lack of implementation meetings. For approaching a decade serial efforts
Surgical Care
have been made to improve provision of spinal care (NHSE Spinal Taskforce Reports). NHS England has now appointed a project team to support the current Improving Spinal Care project (ISCP). There are two main elements: • The national low back and radicular pain pathway • The regional spinal networks project Details of both the NHSE Spinal taskforce reports and the ISCP project are on the United Kingdom Spinal Societies Board (UKSSB) website - www.ukssb.com. As with MSCC, the low back involves multidisciplinary
Communication and Actions
RCS
BOA
SBNS UKSSB
BSS
BASS
SBPR
working. There are three streams involved in the care of patients with low back pain. Surgical, non-surgical and those involved in communication. Effective communication between these three groups is essential in the implementation of low back pain care across the multidisciplinary environment (Figure 3). To effectively implement this across a multidisciplinary framework it is necessary to communicate to all. An updated NICE guideline on low back and radicular pain is currently consulting and we plan to use our experience from MSCC to implement the recommendations. Multidisciplinary meetings of the type described above are being considered; these may
Non-Surgical Care GP, Emergency medicine Pain Specialists Rheumatology BSR Radiology Diagnostic Radiology - interventional Sports Medicine BIMMS Physiotherapy Chiropractic Osteopathy Rehibilitation Psychologists
SBNS (Society of British Neurological Surgeons); BSS (British Scoliosis Society); BASS (British Association of Spinal Surgeons); SBPR (Society for Back Pain Research)
Figure 3: Evolving proposed structure for communication and combined action
need to be regional as a result of the larger numbers involved in treating the degenerative spine. Service implementation meetings might precede or link with national professional society meetings. Funding will be an issue, although preferential rates for allied health professionals should be considered to enhance attendance. To enable communication, there is now a quarterly eBulletin “Spine Matters” published on the UKSSB website with serial updates from the Improving Spinal Care projects leads and from each of the spinal societies. There is an old African saying “If you want to travel fast - travel alone; if you want to travel far - travel together”. Service improvement will come from getting people working well together. The process for MSCC was instructive, enjoyable, and productive and will hopefully assist with low back and radicular pain. Can we widen this approach to other clinical arenas? In closing I would like to give credit to all who have contributed so much to these developments but in particular on the surgical side John Carvell, Charles Greenough, Ashley Cole, Nigel Henderson, Tim Pigott, Ian Nelson and Rick Nelson. n Alistair Stirling is a Consultant Spinal Surgeon at The Royal Orthopaedic Hospital Birmingham. He is Chair of United Kingdom Spinal Societies Board (UKSSB) and is on BOA Council. He was Lead Clinician on the NICE guideline CG75 Metastatic Spinal Cord Compression (MSCC) and NICE Quality Standard QS56 MSCC.
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Volume 04 / Issue 02 / June 2016
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JTO Features
The Bone and Joint Decade Global Alliance for Musculoskeletal Health: A Lay Perspective Nick Welch
Before I was nominated to be elected as an International Ambassador to The Bone and Joint Decade Global Alliance for Musculoskeletal Health (BJD) I did not know of its existence. This has made me wonder who else is unaware of the Alliance’s existence and its goals.
The BJD is a global organisation whose expressed goals are to raise the recognition of the importance of musculoskeletal conditions at global, regional and national levels by: • Raising awareness of the burden of musculoskeletal conditions; • Developing sustainable networks; • Increasing knowledge of the suffering and costs of musculoskeletal conditions; • Empowering people to prioritise their own care; • Improving access to costeffective prevention and treatment; • Increasing research into musculoskeletal disorders, prevention and treatment; • Providing access to supportive information.
Nick Welch
In Europe, Africa, Asia and the Americas there are dedicated ambassadors seeking to raise the profile of musculoskeletal disease and its human and economic impact on society. They also help develop their National Action Networks, facilitate strategic contacts and work with the
International Coordinating Council to achieve the goals of the BJD. The Arthritis and Musculoskeletal Alliance (ARMA) co-ordinates the British National Action Network... and currently Professor Anthony Woolf, Professor of Rheumatology, chairs the International Coordinating Committee. It is worth visiting the website for more information http://bjdonline.org. From my perspective in the UK, and England in particular, the often fractionated and costrestrictive commissioning of musculoskeletal conditions, some even blacklisted as ‘procedures of limited clinical value’, means patients suffer unnecessary pain and mobility issues. The social and health economies suffer because these people cannot contribute fully to society, whilst also needing costly support. There are three groups in this arena: the commissioners, the social- and health-care providers and the patients:
• It is the responsibility of the commissioners to ensure sufficient funds are put aside to provide an integrated social- and healthcare programme for all patients with musculoskeletal disease. They have the dual objectives of managing current patients, as well as preventing the various conditions in future generations; • All social- and health-care providers should work together to ensure that every patient has an optimised and individualised care pathway, which includes treatment, palliation and self-awareness training. It is also important to identify people at risk of musculoskeletal disease and provide the necessary support to help them minimise the impact of their musculoskeletal disease on themselves and society; • Every patient has the responsibility to learn what he or she can do to help themselves. Exercise, weight control, smoking cessation and responsible alcohol consumption are all important. This global initiative is worthy of wider exposure, and greater support. Its objectives are nothing more than common sense promoting the needs of patients over the diktats of the ‘pen-pushers’ is an on-going and seemingly endless battle. Tally-ho!!!! n Nick Welch is a Past Chair of the BOA’s Patient Liaison Group. He was recently appointed an International Ambassador for the Bone and Joint Decade, and is the PPI representative on several orthopaedic trials.
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Volume 04 / Issue 02 / June 2016
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JTO Features
Principles of the BOA Instructional Course – how it works now Danny Ryan, BOTA Education Representative Contributing author: Mike Reed, BOA Education Committee Chair
The BOA Instructional Course has been a pillar of the BOA’s education calendar for over four decades, providing trainees with a whole weekend dedicated to exam-focused teaching for the FRCS. However, over this time we have seen training evolve rapidly, with a move from paper-based logbooks to online portfolios, and an embracing of more modern educational theories and formative assessments to support learning. When delegate numbers began to decline, it became clear that the BOA Instructional Course needed to evolve.
Danny Ryan
Current trainees are part of the ‘Google generation’, raised in the age of the Internet, with a wealth of knowledge at their finger-tips and the knowledge of how to access it. Finding information no longer requires searching for a textbook or journal article, or sitting in a dark lecture theatre; it is available at the click of a button. Furthermore, trainees are adults with reallife goals and aspirations, staring up at a tornado of CCT guidelines relating to workplacebased assessments (WBAs), indicative operative numbers, research, quality improvement, management, human factors and leadership, all aimed at preparing
for life as a consultant trauma and orthopaedic surgeon. The FRCS exam is only one part of this mélange of factors, raising the question: how do we engage with this dynamic and diverse group of individuals? In January 2015, the BOA Instructional Course was reinvented in order to address these issues, shifting focus away from lectures, to helping trainees develop their higherorder decision-making processes. High-quality lectures on FRCS and curriculumlinked topics remain, but have been shortened in length and bolstered by large-group
seminars, where the intricacies of cases can be discussed in a viva-style. The most significant change, however, has been the introduction of Critical Condition Case-Based Discussions (CBDs). Critical Conditions are a series of conditions in which a misdiagnosis can result in devastating consequences for life or limb. It may be possible that the trainee does not encounter these during their training, but when they do, they should be able to recognise and manage them appropriately. The BOA Instructional Course now offers an opportunity for trainees to take part in small group CBDs in order to attempt to achieve a ‘level 4’ in the selected Critical Conditions, facilitated by expert consultants in the relevant fields. Preparation is required, with instructions regarding topics disseminated in advance via a screencast. It is important to understand that attending the course does not guarantee a ‘level 4’ in the included CBDs, but provides a strong learning environment, among peers, where this is possible. The BOA Instructional Course 2015 saw trainees engaging in furious periods of cramming for sessions, with obvious disappointment if facilitators gave feedback with a lower ‘level’. However, the real benefit lies in the interactions and feedback to the trainee from
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these sessions. With greater time allocated to each Critical Condition, trainees are able to appreciate the formative nature of the exercise. Purists have suggested that such flexing of WBAs does not fit with the original aim of the tool. However, the ISCP evaluation of 2012 asserts that “More effort needs to be directed at making explicit the fact that ISCP is used differently in different settings. As long as the ISCP record makes it clear that the assessment took place outside the clinical context, on an instructional course, such initiatives are to be welcomed”.
Undoubtedly, the high pace of the weekend requires thorough planning (next year’s timetable has already been drafted), efficient execution, and an energetic faculty, but as the spotlight turns on trainers to provide evidence of their involvement in teaching and education, the BOA Instructional Course also provides clear benefits to facilitators. Currently, trainees are allocated time to prospectively complete CBDs on ISCP for validation by trainers during the weekend, thereby preventing both ‘decay’ of memory of the learning event
or the creation of a ‘backlog’ of WBAs for validation. Trainers can create a record of the WBAs they have validated, for their portfolios, as evidence of their engagement with trainees on a national, curriculum-based course. Furthermore, in 2016 a newly proposed Critical Condition, necrotising fasciitis, was trialled with great success, showing the value of trainee input at the Course, and informing the T&O curriculum. The BOA Instructional Course is ahead of the curve in how it provides a spectrum of teaching, delegate participation and WBA validation that is not provided
elsewhere. Feedback from 2015 was invaluable in improving the 2016 Course, with over 90% of trainees stating they would recommend it to colleagues. The 2017 Instructional Course will run on 7th-8th January. For more information, please contact policy@boa.ac.uk. *ISCP management group. ISCP evaluation report; 2012 n Danny Ryan is the BOTA Education Representative. He is ST4 in the Severn Deanery and a Clinical Tutor at the University of Bristol.
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JTO Features
New leadership outlines exciting vision for ORUK Dr Arash Angadji, Chief Executive, Orthopaedic Research UK
I am delighted to be leading Orthopaedic Research UK (ORUK), one of the country’s leading orthopaedic research charities. 2016 marks the beginning of an exciting new chapter in the charity’s story as we implement key organisational change and a new strategy to better enable us to improve the quality of life for people with bone and joint disease.
As I write there are some 8.5 million people in the UK affected by orthopaedic disease. For many, their condition will respond to existing and effective treatments, but for others it can mean a life blighted by pain, disability and social isolation. Funding research is at the heart of what we do. We are one of the most significant funders of orthopaedic research in the UK having invested over £8.5m in the field and supported nearly 130 individual projects. We plan to significantly increase the amount of funding we are able to offer in coming years, but the key is to incentivise and fund high quality translational research that delivers outcomes which are real and meaningful for patients. We want to promote innovation and are keen to encourage collaboration and partnership with a wide range of organisations across the scientific, medical and academic communities, as well as industry.
Dr Arash Angadji
We have an excellent partnership with the British Orthopaedic Association. We have provided funding to
support the creation of UKITE, a national, online examination allowing trainees to practice for FRCS T&O examination. We are also currently funding three BOA projects, to the tune of more than £136,000. These projects are the ORUK Clinical Fellow at the BOA Orthopaedic Surgery Research Centre in York; a shoulder dashboard led by Mike Reed in Northumbria; and the production of educational podcasts. Fundamental to our work is the further education, in both surgery and research, of young surgeons, scientists and engineers. As well as funding and publicising cutting-edge research we also organise conferences, symposia and lectures to educate and promote collaboration. Over the next three years ORUK plans to develop its role as a leading provider of education and training with an expanding number of courses throughout the UK. Alongside our popular FRCS (Orth) revision courses, we will deliver other CPD accredited events to encourage interaction and provide valuable networking opportunities. For further information please visit: www.oruk.org/news-andevents/events.
Please do get in touch to find out how you can get involved and support our vital work, transforming people’s lives today and working towards our ultimate aim of eliminating bone and joint disease. n Dr Arash Angadji was appointed as the Chief Executive of ORUK in January 2016. He has had a distinguished career in orthopaedic science and has worked for ORUK for eight years. Arash has been instrumental in the strategic development of the charity and its strong focus on translational research. Since 2008 he has regularly taught on University College London’s MSc course in Biomaterials and Tissue Engineering.
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Advertiser’s Content
When turning away patients improves your bottom line Why turn patients away?
Imposters
Private practice is competitive, even for orthopaedic and trauma specialists. Many assume that building a successful practice means taking on every available patient. After all, in NHS practice it is relatively rare to turn anyone away. The problem comes if you adopt that mind-set in private practice, where you can and sometimes should reject prospective patients (except for discriminatory reasons).
Some patients use others’ health insurance to obtain private treatment. Since every type of insurance gets fraudulent claims, private health insurance cannot be immune. The health insurers you work with may expect you to do identity checks. If not, consider introducing them. For example, your receptionist could ask for a credit or debit card to check the name and signature against the forms filled out by the patient.
Profitable private practice depends on good patients, because the wrong patients cost money. They cause more claims, which can lead to you paying settlements or compensation out of your medical indemnity policy excess. They also take time away from other paid work. Rejecting a patient can be the most effective risk management action you can take. We have provided detailed guidance to our members on this topic as part of the risk management aspect of our service. Here we highlight a number of ways to improve your patient selection processes to help prevent fee disputes, complaints and claims arising in the first place.
If the insurer discovers that you treated an imposter, they might allege that you somehow facilitated that fraud or breached your duties to them. A GMC investigation could follow. Even where you are completely exonerated, you could still be out of pocket if you had to pay something towards legal representation costs, or missed out on paid work while dealing with the allegations. The chances of you becoming the secondary victim of such a fraud may be slim, but the consequences so severe that checking all patients’ identities could be worthwhile.
Personality or mental health disorders
What’s your ‘risk appetite’?
Some people are predisposed to dissatisfaction with surgical outcomes, and/or to making unreasonable complaints or claims. When taking a medical history, include questions to screen for personality or mental health disorders, and get guidance as to what questions work best.
Some patients are risky because of their profession or net worth. For very high earners or professional sportspeople, even a minor adverse outcome could prevent or delay them returning to their previous elite or lucrative positions, and to prompt a disproportionately large claim. How much risk are you willing to accept? You might be happy to accept high net worth patients, and to perform very risky procedures. But accepting patients who are both high net worth and in need of a risky procedure may expose your practice to an unacceptable risk of large claims.
In a serious case the patient might not be capable of consenting, so it would be a breach of duty to treat them. In other cases the disorder may not make it necessary to reject the patient. The key is to know when you need more detail about the patient’s personality and mental health to make an informed decision over whether, and if so how, to treat them. Where you take on such a patient, consider how their mental state might affect how you give your clinical advice (will this patient respond better to advice in person?) and what clinical decisions you make (extra pain management?). This helps you to provide appropriate care, and in turn reduce the risk of complaints and claims.
How to reject patients If you decide that you cannot or should not treat any particular patient, trust your gut. Plan how to explain your decision in an honest but sensitive way. After all, you can still help the patient by recommending a suitable alternative specialist for them to see, or by referring them back to the NHS.
Joanne Staphnill Partner (Solicitor) at Triton Global Ltd, medico-legal advisor to OrthISIS. OrthISIS, part of the ISISIS Group, is an indemnity scheme for orthopaedic surgeons with independent practice in the UK. For more articles from Triton, register online at www.orthisis.co.uk.
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JTO Features
The Management of Metastatic Bone Disease Robert Ashford, on behalf of the BOOS MBD Working Party
Metastatic bone disease (MBD) is the final common pathway of multiple malignancies. MBD can result in sequelae such as pathological fracture, spinal cord compression and bone pain requiring radiotherapy. In an attempt to improve the care of patients with MBD guidelines were published in 1999 by the British Association of Surgical Oncology1 and shortly thereafter by the British Orthopaedic Association/ British Orthopaedic Oncology Society (BOOS)2.
In the intervening years, with improvements in anti-cancer treatment, life expectancy has increased in patients with MBD. It is not uncommon for patients with metastatic bone disease to live for five years, following the diagnosis of their bone metastasis. The orthopaedic surgeon has a number of roles to play in the management of MBD3. These roles can be diagnostic or therapeutic. Therapeutic include prevention of fracture, treatment of pathological fracture and in a small number of cases potentially curative excisions. Orthopaedic management of metastatic disease should always be seen in the context of the primary tumour.
Robert Ashford
In light of these improvements in life expectancy, BOOS has revisited and updated their guidance on the management of MBD. This guidance is now available on the BOOS Website (www.boos.org.uk) and will shortly be available on the BOA website. The document
is also endorsed by the British Association of Surgical Oncology. Fundamental to the new document is the care of the patient with MBD. The document is considerably more evidence based, than the previous version. However, level 1 evidence in MBD is extremely uncommon, particularly in surgical treatment. Thus expert opinion has been important in drawing up the document. The object of surgery in patients with MBD remains the relief of pain and the maintenance of function. Despite many advances in orthopaedic surgical care, many patients are still not referred for an orthopaedic opinion until too late. Lytic deposits are still treated with radiotherapy alone, until the situation becomes catastrophic. The guidelines include four minimum standards of care and a number of key points. The minimum standards of care are non-controversial and would be expected by any patient:
1. All patients with MBD should have access to an expert orthopaedic opinion as part of their multidisciplinary care. This may reduce the complexity of surgery by identifying potentially surgically treatable lesions earlier. 2. Treatment options should be discussed with the patient’s oncologist and seen in the context of their underlying malignancy. This will help guide prognosis and inform the orthopaedic surgeon about appropriateness of any surgery. Rapidly progressive visceral disease may be a contraindication to orthopaedic surgery. 3. Follow-up after surgery should include evaluation of fracture union, disease progression and potential or actual implant failure. 4. Data should be captured on the orthopaedic management of MBD to improve understanding of management of this condition. The key points in the document are grouped into infrastructure, diagnosis, prognosis and treatment. In terms of infrastructure, each orthopaedic unit should have a nominated lead clinician for the management of MBD. This should facilitate liaison with the oncology service. The fact that pathological fractures are not emergencies is fundamental to patient care. There is no rush to fix a pathological fracture. In the majority of cases splintage or traction should be utilised, until
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investigation is complete. Imaging should be performed promptly. Biopsy is increasingly performed, either to clarify diagnosis or alternatively to assess whether there has been a change in immunophenotype between the primary tumour and the metastasis. The default position is that a solitary bone lesion should always be biopsied. The increased survival of patients with MBD is the rationale behind the document. Increased survival necessitates a more durable reconstruction. Survival in excess of five years is not uncommon. Treatment of MBD requires an understanding of the disease. In addition to life expectancy determination, fractures may not unite and therefore replacement may be superior to fixation, particularly in the proximal femur. Cemented prostheses, rather than uncemented, should be used. Reconstruction should allow for immediate weight bearing. In the new guidelines, the different treatment options for anatomical regions commonly affected by MBD are discussed. A new chapter on pelvis and acetabulum highlights the importance and complexities of this area. Liaison with the anaesthetic team is emphasised, because of the potential for significant bleeding. Wide excision of metastases is controversial, but it is broadly considered reasonable when resectable metastases present several years after the primary tumour. Extensive bone destruction is also treatable by endoprosthetic replacement in many cases. Endoprosthetic
BOOS MBD Working Party
replacements have evolved over recent years and off the shelf modular prostheses are available for the femur, proximal tibia, proximal humerus and hemipelvis.
Roger M. Tillman (Co-Chair), Robert U. Ashford (Co-Chair), Birender Balain, Thomas Beckingsale, Timothy W. R. Briggs, Gillian Cribb, Craig Gerrand, Jonathan Gregory, Duncan Whitwell
The guidelines for the management of spinal metastases should be read in conjunction with the NICE guidelines for Metastatic Spinal Cord Compression (MSCC)4. The two documents should be complementary and optimise care for patients with MBD and MSCC. Thromboembolic prophylaxis is controversial in all branches of orthopaedics. Patients with cancer are at high risk of thromboembolism. However, bone metastases can be hypervascular and agents that precipitate bleeding are undesirable. That said, no single antithrombotic prophylaxis is suitable for all MBD patients. The guidelines recommend an individualised approach for each patient. The guidelines recognise the established and evolving roles of non-surgical treatment including chemotherapy, radiotherapy, hormone therapy, bisphosphonates and denosumab. The use of these therapies emphasises the importance of a multidisciplinary approach to the management of MBD. Finally, the need for follow up is highlighted. Ongoing symptoms may be a sign of disease progression or impending implant failure (Figure 1). Both of these are easier to address before metalwork failure occurs.
References
Figure 1: Broken cephalomedullary nail inserted for a metastasis. Salvaged by proximal femoral replacement. Ongoing symptoms should result in continued orthopaedic follow up.
Conclusions In summary, the new BOOS/ BOA Metastatic Bone Disease Guidelines represent a significant improvement on the previous version. The importance of multidisciplinary care is emphasised. The use of new minimum standards of care and key points make the document easy to read and hopefully relatively simple to implement. The document will hopefully improve the care of patients with MBD. n Rob Ashford is a Consultant Orthopaedic and Musculoskeletal Tumour Surgeon at the University Hospitals of Leicester. He is Lead Clinician of the East Midlands Sarcoma Service and was Co-Chair of the British Orthopaedic Oncology Society Metastatic Bone Disease Guidelines Development Group.
1. British Association for Surgical Oncology Guidelines. “The management of metastatic bone disease in the United Kingdom. The Breast Specialty Group of the British Association of Surgical Oncology.” Eur. J. Surg. Oncol. 25 (1999): 3-23. 2. Tillman, Roger M., and BOA WORKING PARTY. “Metastatic bone disease: a guide to good practice.” London: British Orthopaedic Association and the British Orthopaedic Oncology Society (2001). 3. Tillman, Roger M. The role of the orthopaedic surgeon in metastatic disease of the appendicular skeleton. J Bone Joint Surg 81B 1-2, 1999 4. NICE. Guidelines for the management of metastatic spinal cord compression (CG75). www.nice.org.uk/guidance/cg75
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JTO Features
Fracture Clinic Redesign John Keating & Tim White
The traditional fracture clinic model has persisted largely unchanged for many years in most UK hospitals. Although operative treatment of many fractures has gradually increased in popularity over the past few decades, the majority of fractures still follow low energy trauma and are amenable to non-operative treatment.
John Keating
Tim White
Most fracture clinics accept unselected, and theoretically unlimited, referrals from Emergency Departments. Whilst this has worked relatively well in the past, many orthopaedic departments have recently experienced a change in referral patterns, with increasing overall numbers of patients being referred with less severe injuries. Contributory issues appear to be reduced orthopaedic experience amongst referring staff in Emergency Departments, exemplified by the loss of the word ‘Accident’ from A&E, increased referrals by more junior doctors or, increasingly commonly, non-medically
qualified extended scope nurses or physiotherapists, and the loss of ED review clinics for minor musculoskeletal injuries. These problems are compounded by an emphasis on arbitrary waiting time targets. The result is an unsatisfactory increased burden on fracture clinics, coinciding with a decrease in the numbers, hours and experience of orthopaedic trainees. Patients are frequently expected to accept a long wait on two successive days to see two different, relatively junior members of staff, only to be given the same advice and discharged. In response to this some centres have looked at methods of controlling the quality and volume of referrals by a process of screening. This practise has been termed a “virtual fracture clinic” but a more appropriate term would be a trauma triage clinic (TTC). Models vary but the main elements are a review of ED clinical records and radiographs by a consultant orthopaedic surgeon. Patients who do require review are brought back to a fracture, or specialist, clinic at the most appropriate time, and may have appropriate investigations ordered in advance. Patients may be invited directly to a nurse-led clinic or a course of physiotherapy. Patients who are considered to require specific advice but not necessarily a fracture clinic appointment are phoned by extended scope >>
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JTO Features
THE MAIN ADVANTAGES OF THIS SYSTEM ARE THAT PATIENTS ARE NOT SUBJECTED TO UNNECESSARY FRACTURE CLINIC ATTENDANCES AND LONG WAITING TIMES, AND INSTEAD ARE TRIAGED TO THE MOST APPROPRIATE CLINIC, TO SEE THE MOST APPROPRIATE CLINICIAN AT THE MOST APPROPRIATE TIME.
practitioners who provide guidance on management. Patients judged as not requiring any further investigation or treatment are discharged. Importantly, immobilisation of stable injuries for comfort is with removable orthoses rather than plaster, allowing the patient to independently adjust and dispose of the splint as required, rather than being required to attend a plaster room. All patients are provided with advice leaflets, either general or specific to the minor injury sustained, at the time of ED attendance, with a telephone number to call in case of difficulty or uncertainty. The main advantages of this system are that patients are not subjected to unnecessary fracture clinic attendances and long waiting times, and instead are triaged to the most appropriate clinic, to see the most appropriate clinician at the most appropriate time. Clinics are reduced to manageable levels, allowing adequate time for senior assessment of complex or potentially problematic injuries, and for training and discussion. Critics of fracture clinic redesign have highlighted the same issues of inexperience and the potential for harm in discharging patients with potentially unstable injuries on the basis of a junior assessment and potentially inadequate radiographs. Examples include
injuries that may be subtle or are commonly missed, such as carpal and tarsal dislocations, posterior shoulder dislocation and multiligamentous knee injuries. The response is that these injuries may be missed in the ED and not referred at all under any system of protocols. However, since the threshold for TTC referral is low, the majority of injured patients have their notes and radiographs screened by an experienced orthopaedic surgeon. We believe that this is a key part of the safety of a TTC system which enables identification of potentially suspicious cases and arranging timely clinical review. To date there is limited evidence of the effectiveness of this type of fracture clinic redesign but the published studies1,2,3 suggest that the changes seem to be associated with safe delivery of care while reducing inappropriate attendances, and maintaining patient satisfaction. The effect of pathway redesign may be related to the volume of patients being seen, and our own experience in Edinburgh is that since its inception in November 2013, our TTC has reviewed more than 1,000 referrals per month, nearly 30,000 referrals in all. This has reduced the number of patients attending the surgical clinic by half. There has been a dramatic reduction in patient complaints about the quality of our fracture service and we have yet to identify a significant clinical
error. Screening by consultant orthopaedic surgeons has been incorporated into job plans based on the number of cases triaged per week. In conclusion, our experience with the TTC system and the available published evidence suggest that a well-designed trauma triage service for patients with musculoskeletal injuries is a safe and effective innovation. n John Keating and Tim White are Consultant Surgeons in the Edinburgh Orthopaedic Trauma Service. Tim is Clinical Lead for Trauma in Edinburgh; John has previously been both Clinical Lead and Clinical Director, and is President Elect of the Orthopaedic Trauma Society. Their main clinical research interests are in the management of orthopaedic trauma and they are the co-convenors of the annual Edinburgh International Trauma Symposium.
References 1. Brooksbank K, Jenkins PJ, Anthony IC, Gilmour A, Nugent MP, Rymaszewski LA. Functional outcome and satisfaction with a “self-care” protocol for the management of mallet finger injuries: a case-series. J Trauma Manag Outcomes. 2014 Dec 10;8(1):21. doi: 10.1186/s13032014-0021-y. eCollection 2014. PubMed PMID: 25516768; PubMed Central PMCID: PMC4266946.
2. Vardy J, Jenkins PJ, Clark K, Chekroud M, Begbie K, Anthony I, Rymaszewski LA, Ireland AJ. Effect of a redesigned fracture management pathway and ‘virtual’ fracture clinic on ED performance. BMJ Open. 2014 Jun 13;4(6):e005282. doi: 10.1136/ bmjopen-2014-005282. PubMed PMID: 24928593; PubMed Central PMCID: PMC4067811. 3. Jayaram PR, Bhattacharyya R, Jenkins PJ, Anthony I, Rymaszewski LA. A new “virtual” patient pathway for the management of radial head and neck fractures. J Shoulder Elbow Surg. 2014 Mar;23(3):297-301. doi: 10.1016/j.jse.2013.11.006. PubMed PMID: 24524978. The BOA’s position statement on Virtual Fracture Clinics can be found on the website www.boa.ac.uk/pro-practice/ virtual-fracture-clinic-statement. The Editors are interested in your views. Please send correspondence to jto@boa.ac.uk.
visit-belfast.com
Belfast is packed with history, culture, exciting events, great food, super shopping - you might even spot a ship or two. You’ll also find some of the friendliest people you’ll ever meet.
To help you make the most of your trip to Belfast we have picked out our top ten things to do when you are in the city for your conference.
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1
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Titanic Belfast The world's largest Titanic visitor experience is a ‘must see’ for any tour of Belfast and Northern Ireland. It’s located in the heart of the city, beside the historic site of this worldfamous ship's construction.
Take a Tour of Belfast Our city centre is compact and can be easily explored on foot. We have a range of tours that allow you to explore the unique history, culture and heritage of Belfast and Northern Ireland.
The Cathedral Quarter The historic heart of Belfast is now the city’s up and coming cultural hotspot. The cobbled streets are dotted with gems of all kinds from restaurants, pubs, art, photographic galleries and even a circus!
Crumlin Road Gaol This nineteenth century listed building is opening its doors, but this time to the public, as a friendly place to explore the gaol’s colourful past.
Ready, Steady, Cook! Awaken your passion for cooking with leading local chefs at one of our cookery schools. Where you’ll be given a step-by-step lesson in creating a culinary masterpiece.
The Murals View the famous political and cultural murals in the west and east of the city - either on a taxi tour or on an open top bus. Remember to add your personal message to the peace wall before you leave.
Sample local produce at the lively St George’s Market Open Friday, Saturday and Sunday, you can sample the local specialist food and products or simply relax with a coffee and newspaper against a backdrop of live jazz or flamenco music.
Guinness, Oysters & Irish music in a traditional Belfast pub Sample a local brew in one of Belfast’s historic hostelries, join in a live Irish music session, or check out the hip and trendy bar and club scene!
City Hall Tour Uncover the history of Belfast City Hall. Explore its splendour and grandeur, proudly created by the craftsmen of Belfast who also worked on the Titanic.
Ulster Museum Come face to face with dinosaurs, meet an Ancient Egyptian Mummy and see modern masterpieces all under one roof. For further information please visit our website or when you are here visit the Belfast Welcome Centre for all your tourist information. +44 (0)28 9024 6609 www.visit-belfast.com
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Belfast named in top 5 of the UK’s best city break destinations. Trip Advisor’s Traveller’s Choice Awards (2014)
1 2 3 4
Titanic Belfast Political Mural Tour Belfast City Hall Dining in Belfast
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JTO Medico-Legal Features
Legal Aspects of Virtual Fracture Clinics Paul J Jenkins, Consultant Orthopaedic Surgeon David A Stephenson QC, Advocate Co-author - Lech A Rymaszewski, Consultant Orthopaedic Surgeon
There is wide interest in the redesign of orthopaedic trauma outpatient services and the adoption of a “virtual fracture clinic” model. The evidence base for the clinical safety and cost-effectiveness of the model continues to grow. This article discusses the medico-legal aspects related to redesign of outpatient fracture clinic services.
When a person sustains orthopaedic trauma they usually undergo initial management in an Emergency Department (ED) or a Minor Injuries Unit (MIU). In most cases they are discharged home following treatment such as splintage and analgesia. The nature of the injury and treatment is explained. They are usually also given an appointment to return to an Orthopaedic Fracture Clinic in the next few days. A patient is discharged from fracture clinic follow-up when the injury is healing and they are regaining function. Paul Jenkins
David Stephenson
Fracture clinics are often busy and rely on the presence of junior
medical staff to deal with the large number of patients. The present system of managing these injuries arose from poor and uncoordinated fracture management in the early 20th century1. With improved primary emergency care, along with the understanding of the nature and natural history of minor trauma, this ongoing utilisation of resources is of questionable efficiency and efficacy. Although the system provides clinic attendees with “face to face” encounters, due to the large number of patients this will often be with a doctor in training, or may be out with the specialist training of the consultant in charge of that clinic. Complex cases that would benefit from specialist senior assessment may have suboptimal care due to this unfocused system. At the same time there may be needless review of minor injuries that would resolve satisfactorily with no further medical input.
The Virtual Fracture Clinic As knowledge of the natural history and management of orthopaedic injuries has improved, it has become apparent that many have been unnecessarily medicalised, which leads to over-investigation and unnecessary follow-up. This can result in prolonged treatment in plaster casts, further x-rays and attendance at repeat appointments2-8. In response to these deficiencies, the Virtual >>
“There is no such thing as public opinion. There is only published opinion.� Winston Churchill
100%
100%
100%
99.73%
20 - 25 years
1. Survivorship of 72 primary total hip replacements (THRs). J.A.N. Shepperd et al Bone Joint J 2013;95-B:467-71
20 years
2. Survivorship of 38 total hip arthroplasties (THAs). N Shah et al Bone Joint J 2015;97B:749-54
13 - 15 years
3. Survivorship of 134 consecutive cases. A.A. Shetty et al J Bone Joint Surg [Br] 2005; 87-B:1050-4
19 years
4. Survivorship in 2,212 cases. J.M. Buchanan, Sunderland Royal Hospital Data presented at BOA 2007, Manchester, 26 - 28 September 2007
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JTO Medico-Legal Features
SEVERAL TYPES OF INJURY WERE IDENTIFIED THAT COULD BE COMPLETELY MANAGED BY THE EMERGENCY DEPARTMENT OR MINOR INJURIES UNIT WITHOUT ONWARD REFERRAL. THESE INJURIES INCLUDED OCCULT AND UNDISPLACED RADIAL HEAD AND NECK FRACTURES, MALLET FINGER INJURIES, FIFTH METACARPAL AND METATARSAL FRACTURES.
Fracture Clinic (VFC) system was introduced at Glasgow Royal Infirmary in 2011. The aim was to improve the clinical effectiveness and the patients’ experience by standardising treatment pathways. This system has spread in a sustainable fashion, based on evidence that we have published in peer-reviewed literature analyses of its safety and patient satisfaction. Several types of injury were identified that could be completely managed by the emergency department or minor injuries unit without onward referral. These injuries included occult and undisplaced radial head and neck fractures9, mallet finger injuries10, fifth metacarpal and metatarsal fractures2. Simple, patient-removable, splintage was provided to relieve pain. Return to everyday activities was advised as early as comfort allowed. Standardised information was provided verbally and via patient information leaflets. A telephone hotline was provided so that if the patient experienced any problems or had any subsequent problems, they could obtain direct, high quality, advice. This process relied on the existing skills of the ED and MIU to diagnose and manage these conditions. All other injuries were referred for review at the following day’s VFC. This runs seven days a week. It consists of consultant review of radiographs and information documented in the ED records. It is conducted in a similar
manner to any other multidisciplinary team (MDT) meeting. A provisional management plan is formulated during the meeting and the patient is contacted afterwards by telephone by a nurse who discusses this plan. Several management options are available: discharged with advice but no further physical review, or review in a subspecialty clinic at the optimal time point for the particular injury. If there are problems with communication, diagnostic or treatment uncertainty, or strong patient preference, physical review is offered. Physical review is also offered for more complex injuries, or injuries where different treatment options are available. In these cases patients are invited for a more detailed discussion in a traditional clinic setting. The results of the VFC discussion and subsequent communication with the patient is recorded via an electronic pro forma in our electronic patient record (EPR; Bluespier International, Worcester, UK). Concerns about the VFC pathway are occasionally voiced by clinicians and include worry that there may be an increase in delayed, missed and erroneous diagnoses, inadequate treatment, and medico-legal claims. Since the introduction in our unit in 2011 there have been no complaints or medico-legal actions arising from diagnosis or management in the virtual clinic. During this period the VFC has
managed approximately 7,000 to 8,000 patients per year.
Medico-legal principles applied to the VFC Facilitation of good quality treatment, consented to by the patient, is a prerequisite for any acceptable model of healthcare. The primary purpose of such a model must be to secure the well-being of the patient. Where systemic or casual departures from acceptable care occur, and the patient has sustained harm, legal claims may result. The VFC pathway should therefore seek to minimise both the risk of unnecessary injury to the individual patient and the risk to healthcare providers of litigation: the two being complimentary aims. Care in a modern UK hospital is delivered by individual practitioners (including doctors) working in a multidisciplinary manner in complex health systems. Protocols and guidelines are increasingly used with a view to providing consistent and evidence-based care. However, the source and status of protocols and guidance may vary. For example, General Medical Council guidance may be advisory or mandatory. Guidelines issued by bodies such as SIGN, NICE, the Royal Colleges and specialist associations may require local adoption and implementation in Unit protocols. The evidence
basis of guidelines, and of individual recommendations within guidelines, may differ: in some instances guidance may, in the absence of a reliable evidence base, rest only upon the consensus of current guideline committee members.
Professional Negligence The foundation of the modern law of medical negligence is in Scotland the case of Hunter v Hanley11 and in England Bolam v Friern Hospital Management Committee12: the cases being of similar effect. A practitioner is negligent if he or she acts in a manner which no equivalent practitioner of ordinary skill would if exercising reasonable care. Where the practitioner acts in accordance with a standard practice, or with a practice that a responsible body of relevant professional opinion supports, then this will normally be sufficient to discharge the duty of care - unless the practice is not applicable to the circumstances of the patient, or the practice can be shown to be irrational, unreasonable or illogical13. In applying the test, recognition needs to be given to the type/grade of the practitioner alleged to have been negligent: in practice a higher standard of knowledge and skill, and thus of care, may be required, for example, of a doctor than of a nurse, and of a consultant than of a junior doctor. The application of the “Bolam
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test” has been removed from the issue of informed consent after the Montgomery ruling in the Supreme Court in 2015 and may still be removed from other aspects of treatment if the lawyers have their way14. What considerations require underpinning an acceptable professional practice in the management of fractures? The General Medical Council provides general professional guidance relating to the primary interaction between doctors and patients in its “Good Medical Practice” guideline15: particularly 15a/b, 16b, 19, 22a, 32 and 45 (see online version). The British Orthopaedic Association is the professional body for orthopaedic surgeons in the United Kingdom. It publishes Standards for Trauma (BOAST) to give national professional guidance. It issued BOAST 7 in August 2013, covering Fracture Clinic Services16. There has been little research performed on the provision of outpatient fracture clinic services and BOAST 7 includes the statement, “this guideline is based upon professional consensus as there are very few scientific studies in the area”. It states that, “following acute traumatic orthopaedic injury, patients should be seen in a new fracture clinic within 72 hours of presentation with the injury. This includes referrals from emergency departments, minor injury units and general practice”. The guideline also recommends
that “all new fracture clinic appointments must lead to a management plan, including any clinical interventions, which is communicated to both the general practitioner and patient in writing”, and that, “there must be a system in place that allows patients rapid access back to the fracture clinic if they have problems related to their initial presenting injury”. The BOAST guideline also states that “there should be local referral guidelines for fracture clinics and any re-design that deviates from these recommendations should be prospectively evaluated to support the change of practice” [Para 13].
Consent Informed consent is required for any episode of medical investigation and treatment (whether conservative or active). The General Medical Council produced their current guidance on consent, Consent: patients and doctors making decisions together in 200817: Paragraph 2 sets out an over-riding duty or principle that requires to be complied with (“you must”). Further paragraphs (2, 5, 7 and 46 - see online version) set out how the over-riding duty should be implemented (“you should”). The information that requires to be provided to a patient in order to secure their valid consent was clarified by the Supreme Court in
the recent case of Montgomery v Lanarkshire Health Board and merits detailed consideration18. Paragraphs 87-91 are particularly relevant (see online version).
Achieving High Quality and Consent in the VFC The VFC pathway allows us to comply with the standards set out in BOAST 715. Locally agreed protocols, that are regularly reviewed, govern which injuries can be directly discharged and which need referred to the VFC for further consideration. Information leaflets ensure that patients receive locally agreed information about their injury, recommended treatment, and anticipated recovery. There are no standards as yet recommending the level of information to be provided by such leaflets. We aimed to provide a readable document that focused on what the patient should expect and who to contact if there were any problems. Patients have reported satisfaction with the information provided. In the future, we anticipate the provision of nationally agreed advice leaflets supported by national specialty and subspecialty organisations. All radiographs are also reviewed by a radiologist, or reporting radiographer, within
24 hours and discrepancies are rapidly investigated. The actual treatment (analgesia and splintage) provided through the virtual clinic system is identical to that which would be provided in a traditional system. The telephone discussion with the patient is similar to that which would occur face-toface. The nature of the injury is explained and the treatment option outlined. The patient can ask questions. Where no further face-to-face review is recommended there must be certainty as to the expected outcome. The patient must also fully understand when and whom to contact when the outcome fails to match expectations. Patients are given hospital contact details for use if they have any problems, or if questions arise in the future. Our VFC is also attended by a nurse from the fracture liaison service to identify patients at risk of osteoporosis and offer them targeted investigation and management. This assists with compliance with a separate standard for trauma (BOAST 9)19. A provisional management plan is decided during the VFC, and then discussed with the patient by telephone by the nurse. Where there is insufficient information to formulate a satisfactory management plan, either because of lack of information from the ED, or >>
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JTO Medico-Legal Features
THE DECISIONS OF THE VFC, AND THE FOLLOW-UP TELEPHONE DISCUSSIONS ARE RECORDED CONTEMPORANEOUSLY IN OUR ELECTRONIC PATIENT RECORD (EPR) WHICH GENERATES A LETTER TO THE PATIENT, THAT IS COPIED TO THE GENERAL PRACTITIONER.
suitable radiographs, a physical review is arranged. If there are communication difficulties (for example, if the nurse making the telephone call is unsure that the patient fully understands the information they have been given), again, further review is arranged. When different treatment options are available and feasible, decision making can be complex. These patients are therefore offered face-toface review in a sub-specialist clinic. When face-to-face review is necessary the VFC process ensures that it is with the most appropriate specialist to provide all the information that is required for the patient to make an informed decision. Finally, if at any point from the phone-call, up to six months following the injury, the patient requests physical review, this is arranged at an appropriate time point depending on the problem encountered. The decisions of the VFC, and the follow-up telephone discussions are recorded contemporaneously in our electronic patient record (EPR) which generates a letter to the patient, that is copied to the general practitioner. The use of an EPR allows regular audit, and we have examined the clinical effectiveness, safety and satisfaction with this process2,9,10,20.
fracture”. Traditional management of the “suspected scaphoid fracture” results in a large number of attendances in traditional fracture clinics. This is usually for re-examination and repeat x-rays at two weeks. There is concern that a missed scaphoid fracture will result in non-union and long term wrist dysfunction. Although the “missed” scaphoid fracture is perceived as an area of significant litigation, the prevalence of claims is in fact low. A recent paper considered the burden of legal action in the area of wrist and scaphoid injuries21. The authors used a Freedom of Information (FOI) request to obtain data over a seventeen year period from the NHS Litigation Authority (NHSLA) covering litigation in the English NHS, and classified the type of claim. There were 73 claims relating to scaphoid fractures that were “settled lost”, and 170 relating to the distal radius. The reported incidence of actual scaphoid fractures in the UK is 29 per 100,000 22. In the same population, the prevalence of true fracture in the overall “suspected” fracture group is 16%23. Assuming a population of England of 53.01 million (2011 Census Data), the expected number of actual scaphoid fractures in this time period was 15,373. Therefore the proportion of all suspected scaphoid fracture cases “settled lost” was approximately 0.07%.
We have introduced a special pathway within the virtual fracture clinic system to manage the “suspected scaphoid
In a similar way, the incidence of distal radius fractures is estimated at 195 per 100,000 24, and the number of “settled lost”
cases was 17021. The proportion of “settled lost” cases to total injuries was therefore 0.16%. In our service, a patient suffering wrist pain following an injury, and having examination findings consistent with an occult scaphoid fracture, has cross-sectional imaging (MRI) arranged directly by the ED. The VFC staff monitor for the results. When results are available, the patient is contacted: where there is no injury, they can mobilise without delay, and if there is a fracture, they can return to clinic for a specialist review. This protocol accelerates access to definitive diagnosis and treatment. We believe that the use of the VFC as a hub for the investigation and management of these injuries reduces variation and the risk of misdiagnosis and management.
Conclusions VFCs have the potential to improve the safety of management through the use of standardised protocols, consultant-led management and release of time to devote to the management of complex patients. VFCs also have the potential to improve the coordination of management of injuries at higher medico-legal risk, such as the suspected scaphoid fracture. When setting up a VFC, adequate attention should be paid to the protocols introduced, information provided in verbal and written formats, recording of discussion and decisions, and application
of the principles of good patient care and consent. Professional negligence claims can be avoided by the use of robust, up-to-date protocols that are based on national standards. Following the Montgomery ruling it is clear that where valid treatment choices exist, a clinician should provide the risks and benefits of each option that that patient would reasonably want to be informed of when making that choice. n Paul Jenkins is a Consultant Orthopaedic Surgeon at Glasgow Royal Infirmary. He has an extensive research interest and has received funding from the Scottish Government to study the quality, safety and effectiveness of fracture clinic redesign. David Stephenson QC is an Advocate (Barrister) and has acted for NHS bodies and medical defence unions for more than twenty years and has extensive experience of clinical malpractice actions.
References The full length article with references can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
Surgical eLearning Opportunities in partnership with the Royal College of Surgeons of Edinburgh PART-TIME ONLINE DISTANCE LEARNING PROGRAMMES FOR SURGICAL TRAINEES |ChM in Trauma and Orthopaedics| |A part-time online distance learning programme for advanced trainees in Orthopaedics| Delivery This two year part-time Masters programme in Trauma & Orthopaedics, taught entirely online, is offered by the Royal College of Surgeons of Edinburgh and the University of Edinburgh, and leads to the degree of Master of Surgery (ChM). Based on the UK Intercollegiate Surgical Curriculum, the programme supports learning for the Fellowship of the Royal College of Surgeons (FRCS) examinations. Trainees will be taught by experienced tutors, all leading clinicians in their field, and will have access to a large structured learning resource of educational materials, including an unparalleled online library facility. Each module includes discussion boards based around relevant surgical cases covering technical skills and procedures as well as core knowledge. This programme provides a quality assured, flexible, and advanced training for the next generation of Orthopaedic surgeons, linking an academic degree to the Intercollegiate Fellowship examination, and further develops the trainee’s academic portfolio and facilitates surgical research projects. Flexible online learning Students on this programme will be part of an online community of Orthopaedic surgeons from all over the world. All you need is internet access and 10-15 hours per week of study which is carried out in a flexible modular manner. Entry requirements UK trainee applicants should have completed initial (ST[specialist training years]1-2) or (CT[core training years]1-2) and early intermediate (ST3-4) phases of their training programme at the time of commencing the course. Applicants would normally be commencing Intermediate Phase (ST5-6) of their training so that the curriculum would be directly relevant to their ‘in the work-place’ experience and prepare them for the FRCS examination which would be completed during Final Phase (ST 7-8). Applicants from outside the United Kingdom or those not within a recognised training programme would require to demonstrate that the course was directly relevant to their Orthopaedic surgery training, and applicants should be able to demonstrate a minimum of 4 years training in Trauma and Orthopaedics before enrolling for the ChM.
Recruiting now for September 2016 entry! Contact us: email: chminfo@rcsed.ac.uk
www.orthochm.rcsed.ac.uk
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JTO Features - Trainee Section
A Time For Change Mustafa Rashid
Recently my first mentor, who inspired me to become a Trauma and Orthopaedic surgeon, retired from the NHS. He was inspiring, supportive, took an interest, and went above and beyond what was expected. Having recently explained to him how his mentorship inspired and motivated me, it made me reflect on my time as a Core Surgical Trainee (CST).
This article highlights the seemingly desperate situation our specialty finds itself in with regards to our junior tier of junior doctors. I will first describe my experience, discuss a recent national initiative that highlights the key issues, and conclude with some ways to reform and improve how we treat junior doctors in Trauma and Orthopaedic surgery.
Mustafa Rashid
As a Core Surgical Trainee, I worked in a department which valued having junior doctors in training. What does that mean? For me, it meant that the experience and opportunities afforded to me were carefully considered by the whole department. I did not really appreciate it at the time, but on deeper reflection, I was very “lucky”. I realised I was lucky because not all of my peers had received the same training opportunities as I had. This department ensured that Core Surgical Trainees, whom they saw as their future registrars, were allocated to clinic sessions and trauma and elective operating lists. Each session was protected, with adequate cover for the wards by other members of staff. Experienced nurse practitioners
involved (Figure 1). Each collaborator prospectively collected data on the junior tier in their hospital. This was defined as doctors working on the “first on call” or “Senior House Office (SHO)” rota. The grade of doctor was recorded. Data was collected prospectively from 08:00 Monday 18th January to 20:00 Friday 22nd January. Collaborators were asked to record for each doctor the clinical activity which they undertook over these five days.
worked well with the junior doctors, enhancing training opportunities, by allowing CSTs to attend theatre and clinic. At the beginning of my term as BOTA President, the BOTA committee highlighted that CSTs were despondent about training. Anecdotally, we all knew this was because they were undervalued, unappreciated, and overworked. The 2015 GMC Trainees Survey results show that our CSTs have a mean overall satisfaction of 75%, compared to the national average of 82%1. The only group of junior doctors in the major specialty programmes with worse satisfaction are the core medical trainees. In addition, nearly 1 in 4 CSTs stated that their current post did not offer significant educational opportunities. The BOTA committee decided to run a national project to examine who the T&O junior doctors in training were and what clinical activities they undertake. The BOTA “Lost Tribe” Audit was conceived, developed, and organised from July 2015 to March 2016. Two hundred and twenty collaborators from 99 T&O departments in NHS hospitals were
Figure 1: Participating hospitals in the BOTA “Lost Tribe” Project
Who are the Lost Tribe? Only 20% of the junior workforce in the 99 hospitals which participated in this project, were CSTs. Twenty-nine percent were Foundation Trainees, mainly FY2’s, 26% were non-training grades (Trust Grade Doctors and LAS doctors) (Figure 2). During the study period, 13% of the workforce was locum doctors. It is important to appreciate that CSTs in T&O form a minority of the junior tier. The mean number of CSTs per T&O department was 1.9. This is important, as it is a manageable proportion of the workforce, who can be given a different working pattern to enhance training opportunities without disruption of the service.
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clinics regularly is just the first step; we must also consider how best to enhance training when they are there. There are few CSTs and I feel this is achievable if consultant trainers and clinical directors are willing to change CSTs working patterns. For example, there is little benefit to a CST providing “ward cover”. Allied Health Professionals can also enhance the quantity and quality of training. Of course there is the concern that AHPs take away theatre training opportunities, this has not been my experience. We must consider the role of AHPs in providing ward cover to allow trainee doctors to be rostered to theatre and clinics. There are financial and regulatory implications to this, but it is currently being done successfully in several hospitals in the UK.
Figure 2: The “Lost Tribe” by Grade
When considering what the “Lost Tribe” actually did for five days, we found that they covered the wards for 28.7% of the time, were on an imposed “zero session,” as a result of European Working Time Regulations, for 32.5% of the time and on-call 12% of the time. They managed to attend theatre lists for just 7% of the time during the study period, and rarely attended clinic (2.7%) (Figure 3). This brief summary highlights why we must act to ensure the junior tier, doctors who have committed to a career in surgery, are given more opportunities to attend the engaging aspects of our specialty. These figures may come as a surprise to some, whilst others may see this as a reflection of their local experience. What is clear is that we must now consider how to change things, not just for junior doctors’ future in T&O, but for the entire specialty. Trauma and Orthopaedic surgery is a busy specialty, accounting
for a significant proportion of hospital admissions. Whilst oncall activities are important for service delivery, they also offer training opportunities. With the new look EWTR-compliant rotas, we are seeing almost a third of time spent in zero sessions. We should consider whether part of this time can be best utilised to provide training in other ways, such as anatomy dissection sessions, extra local teaching, e-Learning modules, and arthroscopic simulation training. There are logistical challenges to this, but it is achievable if the time and resources are invested in. New working patterns, starting with CSTs, allowing protected, bleep-free theatre and clinic sessions should be considered. This may be challenging, but it can be achieved with careful consideration of how the other grades of junior doctors can be used to free up CSTs. Allowing CSTs to get to theatre and
Finally, we must all consider our role in mentorship. From ST3 trainees to the most experienced consultants, we must all do our bit to ensure that the future generation of T&O surgeons are given adequate exposure to an environment in which they can train. Many CSTs feel lost; they need mentorship, guidance and
exposure to training opportunities. It is also important that they feel appreciated for what often seems like a long, unrelenting, slog. In this article I have set the scene for the position which CSTs find themselves in. I have highlighted the lack of clinical exposure for this group of doctors. Finally, I have outlined the three key areas for potential change, to ensure that the future generation receives the necessary opportunities they require to progress successfully into what is a rewarding career. n Mustafa Rashid is a ST5 Orthopaedic Specialist Trainee (Percivall Pott Orthopaedic Rotation) and the current President of the British Orthopaedic Trainees Association (BOTA). He is currently reading a PhD at the University of Oxford investigating predictive modelling for rotator cuff repair integrity.
References 1. http://www.gmc-uk.org/ education/national_summary_ reports.asp The Editors are interested in your views. Please send correspondence to jto@boa.ac.uk.
Figure 3: Clinical activities of junior doctors in T&O
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JTO Peer-Reviewed Articles
The increasing trend in the surgical management of children’s fractures Dennis Kosuge & Matthew Barry
Childhood fractures are common and are estimated to account for up to 25% of all paediatric injuries1. In the United Kingdom (UK), the peak incidence of paediatric fractures is younger in girls (11 years) than boys (14 years). This difference may be related to the discrepancy between height gain and bone mineralisation during puberty2.
The incidence may be decreasing in Scandinavia3, an observation which has not been repeated in the UK1. In Helsinki, the annual fracture incidence in 2005 was 163 per 10,000, an 18% decrease from 1983. In the UK, the incidence was 138 per 10,000 in 1990 and in 1997 it was 135 per 10,000. Potential explanations for this change include improved standards of living and levels of education, in addition to the movement of populations from rural to urban areas. When looking at specific fracture groups, there appears to be an increasing incidence of forearm fractures. This finding is uniformly reported in studies from Europe, Asia and the United States4,5,6,7.
Childhood obesity
Dennis Kosuge
Matthew Barry
Childhood obesity is a growing problem and an association with fracture8,9 has been suggested.
In addition, in children injured in road traffic accidents the rate of extremity fractures is higher in the obese, when compared to the non-obese10. A number of reasons for this increased fracture rate have been proposed, including the momentum effect of a greater body mass during injury, serum leptin levels and differences in gait and balance11,12,13. In addition to the increased risk of fractures, there is concern with regard to the increase in complication rates in the obese. There is a higher incidence of decubitus ulcers and deep vein thrombosis following trauma in obese children14. Therefore, with the potential for obese children to sustain more fractures with more potential complications, operative intervention to stabilise the fracture and allow earlier mobilisation is attractive. Unfortunately, several studies have demonstrated higher complication rates and poorer outcomes using elastic stable intra-medullary nails in children over the weight of 50kg15,16.
Litigation A UK study17 into cases of paediatric orthopaedic trauma that resulted in litigation against the surgeon or National Health Service (NHS) Trust, identified that the most commonly mistreated/ misdiagnosed, >>
DESIGN \ HARVEST.AGENCY
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JTO Peer-Reviewed Articles
were injuries around the elbow, including supracondylar humeral fractures. These injuries comprised 13% of all the litigation cases. A further 3% of litigation cases resulted from intra-operative error during supracondylar fracture fixation. Wrist and forearm fractures and poor plastering or plaster removal techniques, resulting in ulceration or skin lacerations, were also common source of litigation.
Management of specific fractures We have selected three specific fractures, in which controversies in management have been identified, specifically the conservative versus surgical management.
1) Supracondylar humeral fracture (Figures 1 a & b)
Although the overall number of claims is falling, compensation resulting from litigation has increased in the NHS18,19. It could be argued that this litigious environment may affect management decisions in children’s fractures in general, and wrist and supracondylar fractures in particular.
Although satisfactory management of many forearm fractures can be achieved with closed reduction and application of a cast, re-displacement can occur in more than 30% of cases. These may require further intervention30.
The ulnar nerve is particularly vulnerable during insertion of a medial wire for fixation25. A miniopen approach is therefore often used, reducing the risk of direct injury. The rate of iatrogenic ulnar injury is in the region of 3.3% with use of a medial wire26.
The incidence of forearm fractures is increasing with a trend towards surgical stabilisation of diaphyseal forearm fractures31,32. This trend is likely to be due, at least in part, to the lower risks of re-displacement33,34,35. Other relative indications for surgical stabilisation include a shorter period of cast immobilisation with a less frequent clinic follow up. With children’s trauma services becoming more centralised, patients may have to travel some distance. Close supervision of a conservatively managed fracture with frequent clinic attendances could add a significant impact on the family.
Pin site infections are uncommon (0.7% to 2.5%) in large series and usually resolve with oral antibiotics and pin removal27,28,29. Wire fixation is not, however, mandatory and alternative management strategies are discussed in Colton and Monsell’s article (Page 46).
Operative Treatment A population-based study from Finland between 1997 and 200620, reported that the incidence of fractures leading to hospitalisation had increased by 13.5%. This was associated with a 20% increase in fracture surgery. The majority of this increase was accounted for by the increase in upper limb surgery. Over a 10-year period, Cheng et al21 reported that the percutaneous pinning rates of distal radius fractures increased from 9% to 39% and from 4% to 40% in supracondylar fractures of the humerus. This trend towards increasing surgical intervention has also been seen in the management of femoral shaft fractures over a similar time period22.
There are also clear socio-economic benefits with use of wire fixation compared to traction24. Wire fixation has become the treatment of choice and in experienced hands, complication rates after surgery are low and the benefit of a short inpatient stay, make it attractive.
2) Diaphyseal Forearm Fractures (Figures 2 a & b)
Figure 1 a & b: Gartland III Extension Supracondylar Fracture, managed with crossed Kirschner wires
Colton and Monsell have considered controversies in the management of this common injury in detail elsewhere in this issue. General observations include that there is a trend towards wire fixation. This may be a consequence of the perceived poor results from historical studies23 which described the treatment of supracondylar fractures by traction.
Figure 2 a & b: Mid-diaphyseal forearm fracture, managed with Flexible intramedullary nails
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© 2016 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 04, Issue 02, pages 44 & 46-47 Title: The increasing trend in the surgical management of children’s fractures Authors: Dennis Kosuge & Matthew Barry
3) Femoral shaft fractures (Figures 3 a & b)
Figure 3 a & b: Mid-diaphyseal femoral fracture managed with intramedullary nails
Pavlik harnesses, for the under 18 month old, and hip spicas, for the under five year olds, form the mainstay of treatment. Some surgeons use skin traction prior to definitive cast treatment when there is more than 2cm of shortening36. Use of a hip spica cast can result in a number of complications including leg length discrepancy and angular and rotational malunion37. With improvements in surgical techniques and the increasing availability of a variety of orthopaedic implants, femoral shaft fractures are generally managed operatively in children over the age of five years38. Age, size of child, fracture location and pattern are factors that govern the choice
of technique for operative management. The choices include elastic intramedullary nails, internal fixation, either through a traditional open approach or a minimally invasive approach, external fixation and rigid intramedullary fixation39,40,41,42,43.
The surgical management of forearm fractures is also increasing and may be influenced by a desire to avoid plaster casts, which require closer clinical surveillance, are more labour intensive and are also associated with the spectre of litigation.
The choice of surgical management of femoral shaft fractures in children in the over fives has undoubtedly been influenced by socioeconomic factors. The shorter hospital stay is thought to have psychological, educational, social and economic advantages44,45,46. An epidemiological study from Sweden demonstrated the changing trends in treatment, from traction to surgical stabilisation47. The length of hospital stay reduced over the study period from an average of 26 days in 1987 to five days in 2005.
Surgical stabilisation of femoral shaft fractures in children over the age of five years enables the child to mobilise earlier and therefore reduces the length of hospital stay. This is beneficial to the child’s social, educational and psychological needs as well as the economic health of society as a whole. n
Conclusion Fractures in childhood are common and although the incidence has been shown to be decreasing in some population studies, there has been an increasing trend towards the surgical stabilisation of fractures, in particular of the distal humerus, forearm and femoral shaft. The reasons for this increasing trend are multifactorial. Society expects a perfect result, and there is an increasing tendency to early litigation. This is perhaps best illustrated by the management of supracondylar fractures.
Dennis Kosuge was appointed as Consultant in Trauma and Orthopaedics at The Princess Alexandra Hospital in Harlow in 2015. Dennis was formerly on the Percivall Pott Orthopaedic Rotation, during which he developed his interest in trauma and subsequently spent four weeks as AOTrauma Fellow in Japan. Matthew Barry has been a Consultant Orthopaedic Surgeon at Royal London Hospital for almost 20 years with an interest in children’s orthopaedics, trauma, limb reconstruction and deformity correction.
Correspondence Email: dennis_kosuge@hotmail.com Email: matthew@bonedoc.info
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Peer-Reviewed Articles
Supracondylar humeral fractures in children - have we stopped thinking? Christopher Colton & Fergal Monsell
Neurovascular Injury
Although it is unlikely that Hippocrates corresponded in Latin, we respect his attributed primum non nocere as a central tenet of medical practice. Those of us who undertake the management of distal humeral fractures in children would do well to hold to this.
We also benefit from the wisdom of Santayana1 who told us that “Those who cannot remember the past are condemned to repeat it�, yet supracondylar humeral fractures in children appear to be exempt from the rules and reason that govern the contemporary management of other injuries. The purpose of this essay is to examine the conventional dogma associated with this common fracture, and to question some of its firmly-held beliefs, even should this require the sacrifice of sacred cows. The authors’ view is that preservation of neurological function, the prevention of further neurological injury and the avoidance of ischaemic muscular damage are of fundamental importance in management.
Christopher Colton
Fergal Monsell
Good function is to be expected in the majority of cases and the current paradigm of prevention of cosmetic deformity at all costs is not only illogical, but also potentially harmful.
The management of neurovascular complications of this fracture generates much heated debate, which is perhaps not surprising, as the consequences of permanent neurological injury, or a critically ischaemic limb, are devastating. Nerve injuries are common and are estimated to occur in 12% to 20% of all such displaced fractures, with the anterior interosseous nerve predominating2-5. The majority will recover without treatment and the difficulty arises in identifying those that require exploration. Formal documentation of neurological and vascular function at the time of presentation is the first standard for practice in BOAST 116. Frequent reassessment during the period following reduction and stabilisation, whether by open or closed means, is also necessary to identify an iatrogenic injury, which has a reported incidence of 2% to 6% in some series7,8. Ramachandran et al.9 recommended exploration of any nerve injured during reduction and stabilisation of fracture, in the presence of neuropathic pain, a complete lesion with sympathetic paralysis, or a nerve lesion with progressive acute deterioration. Single assessment provides but a snapshot, whereas it is a trend towards deterioration that
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© 2016 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 04, Issue 02, pages 48-51 Title: Supracondylar humeral fractures in children – have we stopped thinking? Authors: Christopher Colton & Fergal Monsell
frequently determines the need for surgical exploration. Mangat et al.10 suggested management strategies for the perfused, pulseless hand, following stabilisation of displaced fractures. They reported a sub-group with tethering, or entrapment, of nerve and vessel at the fracture site and their recommendation was that the patient presenting with co-existing anterior interosseous, or median nerve palsy and a pink, pulseless hand warranted early neurovascular exploration. Blakey et al.11 reported that 23/26 children with a pink
and pulseless hand following supracondylar humeral fracture, at a mean interval of three months following injury, were found to have an established ischaemic contracture of the forearm and hand. They recommended “urgent exploration of the vessels and nerve in the child with pink, pulseless hand, not relieved by reduction, with persistent and increasing pain, suggestive of a deteriorating neurological injury and critical ischaemia”. The authors’ view is that the majority of the recommendations made by Ramachandran et al.
should inform decisions on nerve exploration9. The controversy surrounding the limb with potential ischaemia is in our view, due in part, to the surrogate methods of assessment of limb perfusion. The fundamental goal is to avoid muscle ischaemia with consequent contracture, and assessment must assess muscle perfusion, albeit indirectly. Pulse, digital colour, capillary refill and mechanical methods, including pulse oximetry, do not satisfy this requirement. The simplest clinical test for evolving
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muscle ischaemia is pain on passive digital extension and/or flexion. In our view, the decision to explore a vascular injury or decompress a muscle compartment should be based largely on the presence and deterioration of muscle stretch pain in the period following injury or reduction of the fracture. We consider that the majority of fractures can be managed without exploration of the neurovascular structures and have highlighted specific clinical situations in which rapid exploration is required.
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JTO Peer-Reviewed Articles
Reduction and Fixation
The presence of such deformity often worries uninformed parents, but most will be reassured by knowing that this can be corrected at any time, but preferably at skeletal maturity, by a planned geometric osteotomy via healthy soft tissues.
As early as 1903, Prof. Niehans of Bern used intramedullary pinning to stabilise displaced supracondylar humeral fractures in children, but after open reduction12. In 1988, Pirone stated: “Percutaneous Kirschner-wire fixation is advocated as the method of choice for the majority of (such) displaced fractures”13. In 2014, Ladenhauf stated: “Today, the preferred treatment of displaced supracondylar humerus fractures in children is immediate closed reduction and percutaneous fixation with two or three lateral pins. In case of instability of the medial column, a medial pin may be used, but possibility of iatrogenic ulnar nerve injury should be considered”14. Closed reduction with transcutaneous pinning has now become the promulgated orthodoxy for such fractures and BOAST states that: “These injuries require early surgical treatment; ideally on the day of admission… surgical stabilisation should be with bicortical wire fixation”6. Such dogma deserves careful and thoughtful re-examination as the therapeutic pendulum appears to have become stuck at one of its poles.
Quality of reduction For successful intraosseous pinning, the reduction must be anatomical. The cross-sectional form of the humerus at the fracture site is dumbbell-shaped and if these dumbbells are imperfectly aligned, the target area for safe intraosseous pin insertion is greatly limited (Figure 1). Extraosseous pin insertion risks damage to important anatomical
Figure 1: Any residual fracture displacement reduces the safe corridor for intraosseous pin insertion.
structures, as well as increasing the chances of a failed fixation. For this reason alone, reduction must be achieved to an anatomical, or near-anatomical position and requires careful monitoring with image intensification. Whereas these problems need not necessarily contraindicate closed reduction and intraosseous pinning, such valid caveats are rarely stressed. Powered insertion of Kirschner wires generates heat in the tissues and an important point that passes largely unstated is that the pins should be inserted with an oscillating drill or by hand in health systems where such equipment is unavailable. Thermal injury of the physis, through which the pins are inserted is a danger, especially if multiple attempts are made to insert any one pin. Hunter and Slongo stated: “When placing (inserting) wires across the growth plate, repeated drilling, starting several wires from a single point, and very peripheral insertion must be avoided to minimise damage to the proliferation zone.”15 As educators of future generations of orthopaedic and fracture surgeons, we must condemn
multiple passes of a wire across the physis in an attempt to stabilise an imperfectly reduced fracture. Such a technique of multiple physeal penetrations, in other anatomical situations, is sometimes exploited to secure epiphysiodesis.
Cubitus varus It is not unreasonable to examine current practice in the context of why reduction and fixation are so strongly advocated. With the exception of cases with vascular and neurological deficits, surgery is performed exclusively to avoid cubitus varus following malreduction. Cubtius varus rarely, if ever, results in any functional deficit. It is purely a cosmetic problem in most, if not all cases and usually only evident when the patient is standing in the “anatomical position”. In 1986, Ippolito et al. reviewed 22 patients with cubitus varus following such fractures treated non-operatively, and none had a functional deficit16. Similarly, Labelle et al. found no functional deficit in 63 patients with residual cubitus varus17.
The debate has not yet been joined over what degree of varus malunion is acceptable. There is a gathering medicolegal storm over whether malreduction leading to cubitus varus is negligent and therefore compensatable. In a medico-legal context, supporting a position that any residual deformity is negligent is illogical and redefines reductio ad absurdum. If this be agreed, the surgical profession needs to recognise that it is sometimes better to treat such fractures without immediate operative intervention, recognising the likelihood of subsequent cubitus varus, which may or may not require later surgical remedy. Debate is urgently necessary over the degree of acceptable cubitus varus and if we surgeons neglect to do this, the legal profession will exploit such inattention.
Alternative management strategies It has to be recognised that many children with displaced supracondylar humeral fractures are treated in health-care settings where resources such as image intensification are unavailable and the use of “closed” pinning without such control is hazardous, for all the reasons explored above.
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© 2016 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 04, Issue 02, pages 48-51 Title: Supracondylar humeral fractures in children – have we stopped thinking? Authors: Christopher Colton & Fergal Monsell
The alternative options would then be open reduction and pinning, splintage after attempted reduction (accepting the risk of cubitus varus), or traction, involving methods that include straight-arm and overhead olecranon traction (Figure 2).
for another. Yun et al. described an ingenious technique19 that corrects distal humeral deformity, without secondary lateral translation (Figure 3). There is no place in modern surgery for corrective osteotomies to be conducted without detailed preoperative planning and geometric precision. The correction of a cosmetic deformity demands a cosmetically perfect result. Some authors advocate stabilisation of such osteotomies using external fixation20 and whilst this provides a potentially attractive alternative; it has not become an established part of contemporary practice.
Figure 2: Overhead traction via an olecranon screw. The arm is elevated, thereby reducing pain and swelling: the forearm falls naturally into pronation, encouraging the correction of varus.
The latter two therapeutic options should not be allowed to fall into the oubliette of paediatric orthopaedic history, for want of a rather broader approach than the current dogma of Pirone, Ladenhauf and the BOA’s standard treatment protocol.
Summary The majority of perfused but pulseless hands can be managed expectantly, provided there is no evidence of evolving muscular ischaemia. The majority of peripheral nerve injuries, which are caused at the time of injury and present at the time of first assessment, can also be managed expectantly,
provided there is no evidence of neuropathic pain, or deterioration over a period of 8 to 12 hours.
the AO Foundation. He is currently enjoying life as an educator, boulevardier and master diver.
The current dogma of reduction and transcutaneous pinning of all displaced supracondylar humeral fractures in children should be approached in a more analytical fashion than the simple ex cathedra statements that abound. It is a demanding surgical procedure with risks for patients of the unwary and formulaic surgeon, and there are alternative management strategies for underresourced health care systems.
Fergal Monsell is a Consultant Orthopaedic Surgeon at the Royal Hospital for Children in Bristol. He was an ABC travelling fellow, Past President of the British Limb Reconstruction Society and a Member of the Politburo of the Society for Children’s Orthopaedic Surgery. He is a member of the editorial board of the Bone and Joint Journal and specialty editor for paediatrics. He is married to Ros, has three grown-up children and to his credit is a lifelong Spurs supporter.
Attitudes to cubitus varus malunion, in both surgical and medicolegal contexts, bear careful scrutiny and osteotomies to correct cubitus varus malunion require meticulous planning and precise, geometric execution. Christopher Colton is Professor Emeritus in Orthopaedic and Accident Surgery at the University of Nottingham and was a Consultant Orthopaedic, Trauma and Paediatric Orthopaedic Surgeon at Nottingham University Hospital for more than 20 years. He was an ABC Travelling fellow, BOA President, Founding Trustee and Lifetime Honorary Member of the Board of Trustees of
Correspondence Email: colton1937@gmail.com Email: fergal.monsell@btinternet.com
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
Correction of cubitus varus malunion In 1959, French described a somewhat crude valgus osteotomy for the correction of cubitus varus18. It unfortunately produced the so-called “chicane” deformity, with excessive lateral condylar prominence, as does any such osteotomy that fails to translate medially the distal humeral fragment. Regrettably, such ugly corrections are still practised today, thereby exchanging one cosmetic deformity
Figure 3: Yun osteotomy: A triangle of bone is excised as shown in the left hand diagram: the angle at B is the desired angle of valgus correction. The distal humeral fragment is then rotated and medially translated so that the original point A is moved to point C. The pair of diagrams on the right show how the longitudinal axis of the humeral diaphysis now passes through the lateral portion of the trochlea – the anatomical norm – and the osteotomy if stabilised with crossed pins.
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Management of slipped capital femoral epiphysis (SCFE)
- A nationwide drive to develop evidence based care Daniel Perry Co-authors: BOSS Collaborative Members, Fergal Monsell, Manoj Ramachandran, Deborah Eastwood
Epidemiology SCFE is most common in boys (male: female ratio 1.5:1), and typically occurs between 9 and 14 years1. The annual incidence is approximately seven cases per 100,000 in 6-18 year olds, which equates to a 1:1,200 lifetime risk2. A rising incidence of SCFE has been observed. This has been associated with escalating childhood obesity3, 2, 4. It is believed that obese children undergo mechanical ‘failure’ of the physis, due to excessive physiological loads. Other diseases are also believed to ‘weaken’ the physis, such as trisomy 21, hypothyroidism, hypogonadism, renal osteodystrophy, growth hormone therapy and gonadotrophin releasing therapy5, 6, although these associations are the result of case reports and uncontrolled series.
(AVN), and ‘unstable’ slips have an AVN rate of up to 50%. There is confusion around the term ‘stability’, as clinical stability may not truly correlate with stability of the physis found at open surgery8. The original definition is also widely misused in the literature and everyday clinical care. A meta-analysis of the prognostic significance of ‘stability’ confirmed unstable hips have an AVN risk 9.4 times greater than stable hips9. Other classifications relate to the chronicity or severity of slip10, 11. Chronicity adds little information of clinical relevance, but severity, based on the slip angle, is of value when considering treatment strategies10 (Figure 1).
Classifications
Daniel Perry
The most useful classification is based on the ability of the child to walk, and is termed ‘stability’7. The hip is considered stable when the child is able to walk, with or without crutches, and unstable when the child cannot walk even with crutches. ‘Stable’ slips have a negligible risk of avascular necrosis
Hip shape and osteoarthritis The anatomic abnormality is an anterior slip of the metaphysis relative to the epiphysis through the physis, such that hip flexion results in abutment between the metaphysis and the acetabulum. Severe shape abnormalities of the hip have long been associated with the premature development of osteoarthritis (OA)12, and there is growing recognition of an association between even modest cases of femoroacetabular impingement (FAI) and OA13. There are few long-term follow-up studies, although it appears that more severe deformities reproducibly result in OA requiring intervention14, 15. If all slips are considered, there is a 10% need for reconstruction, by arthroplasty or osteotomy, within 10 years15.
The Evidence for SCFE Surgery
Figure 1: Severity is determined using Southwick Angle. Mild <30 degrees, Moderate 30-50 degrees, Severe > 50 degrees. Southwick Angle = α – α on the normal side.
Since 1950, there have been 380 retrospective studies, six small narrow prospective studies, and no intervention studies16. There is one meta-analysis, and one systematic review examining the surgical treatments17, 18. The conclusions are limited
>>
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ADVOCATES OF URGENT SURGERY SEEK TO QUICKLY RESTORE THE CIRCULATION, WHILST ADVOCATES OF DELAYED TREATMENT SEEK TO PREVENT A ‘SECOND-HIT’ PHENOMENON, WHICH THEY BELIEVE OCCURS AS A RESULT OF OPERATING THROUGH ALREADY INFLAMED TISSUES.
by the paucity of highquality evidence. The British Orthopaedic Association (BOA), and British Society for Children’s Orthopaedic Surgery (BSCOS) have identified SCFE as an area requiring urgent research19.
Current Controversies in SCFE Surgery Surgical strategies vary widely, as illustrated in surveys of the membership of the British, Dutch, European and North American Paediatric Orthopaedic Societies20, 21, 22. These surveys demonstrated that there are predominantly three different subgroups of SCFE, each prompting differing treatment considerations based on stability7 and severity10: • Mild/ Moderate Stable (50%) • Severe Stable (25%) • Unstable (25%) Additionally, treatment of the opposite hip is controversial.
which has developed from the observation of lower AVN rates by the Stanmore group in London23.
Mild/ Moderate Stable SCFE: Should growth of the physis be permitted?
There are several case series which have considered the optimum timing of surgery; the results are mixed25, 23, 7, 24, 26, 27, 28. Advocates of urgent surgery seek to quickly restore the circulation, whilst advocates of delayed treatment seek to prevent a ‘second-hit’ phenomenon, which they believe occurs as a result of operating through already inflamed tissues. A systematic review demonstrated no significant difference whether the treatment was before or after 24 hours although there was a trend towards better outcomes with earlier fixation17. Nevertheless, the advocates of the delayed approach believe that this review asked the wrong question, suggesting that a minimum of one week must elapse to avoid the second-hit phenomenon, and reduce the incidence of AVN23, 25.
The European Paediatric Orthopaedic Society (EPOS) survey of the management of SCFE identified that most observers used a single screw to stabilise the epiphysis in situ22. Conventional screw fixation places threads on either side of the physis, preventing further displacement and preventing further growth. By preventing growth, the remodelling capacity of the hip is limited. Enabling growth of the physis can be facilitated by using smooth wires, or with newer devices such as proximally threaded screws or a ‘growing screw’29, 30. By allowing growth and remodelling, the impingement lesion between the metaphysis and the acetabulum may improve, or even resolve. Likewise, the neck length and abductor function will
Unstable SCFE: When should unstable slips be operated on? There is a belief that the timing of surgery influences the rate of avascular necrosis23, 7, 24. Eightyeight per cent of respondents, in a US survey, supported emergent/ urgent (<8hours) treatment21. However, stabilisation after two to three weeks of bed-rest is commonly practiced in the UK,
Figure 2: Fluroscopy image of a severe slip pinned in-situ with a proximally threaded screw in a 6-year old (left). Radiograph after 3 years of follow-up, and after 3-screw exchanges (right).
be maximised. Encouraging results using these techniques have been demonstrated in a few small series29, 30. However, by allowing physeal growth, there is a risk that the SCFE may recur, as the epiphysis ‘grows off’ the transfixion device (Figure 2).
Severe Stable SCFE: Do severe stable slips necessitate major interventions? This degree of deformity is unlikely to remodel even with growth preservation29. There has been a reluctance to correct this surgically owing to the risk of catastrophic AVN. The 2009 EPOS membership study reported that only five of the 72 respondents advocated open reduction of severe stable slips22. Long-term follow-up studies have suggested that pinning in situ offers the best outcomes irrespective of the severity of SCFE, owing to the complications, particularly AVN, of more invasive operative intervention14, 31. Joint preserving techniques of the hip have recently grown in popularity, particularly the dislocation described by Ganz32. Ganz has reported on his technique in SCFE using a modified Dunn technique. None of the hips developed AVN and although three required revision for implant failure, all had universally good
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Journal of Trauma and Orthopaedics: Volume 04, Issue 02, pages 52 & 54-55 Title: Management of slipped capital femoral epiphysis (SCFE) Author: Daniel Perry Co-authors: BOSS Collaborative Members, Fergal Monsell, Manoj Ramachandran, Deborah Eastwood
patient reported outcomes33. Other groups have also demonstrated good results using Ganz’s technique34, 35, 36. POSNA recently presented this as the ‘ideal’ treatment of stable moderate and severe SCFE, assuming adequate surgical expertise37, 38. However, other studies have raised concerns, with high rates of AVN, albeit in a group of unstable SCFE39, and a group of mixed stable and unstable SCFE40. There were also other significant complications, including implant failure, hip instability and femoral neck non-union39, 40. Technical difficulty is usually cited as the primary reason for failure, with the notion that large numbers are required to achieve and maintain competence amongst surgeons. Other ‘nondislocation’ joint preserving techniques previously described include cuneiform osteotomies via an anterolateral approach (Fish)41, 42, and via a lateral approach (Dunn)43, 39; both are also known to have notable risks of AVN44, 45, 46, 47, 48. It is unclear if the complications of deformity correction are too great to justify deformity correction over conventional pinning in situ. The National Institute for Health and Care Excellence (NICE), have reviewed this subject (IPG511), and recommended that strict governance arrangements and monitoring be in place in centres undertaking these procedures.
Opposite Hip: Should the unaffected hip undergo prophylactic fixation? A systematic review, which included over 200 studies, estimated that 19% of patients with an initial unilateral SCFE subsequently developed a contralateral slip, usually in the first 18 months after diagnosis49. Whilst stabilisation of the contralateral epiphysis mitigates this risk, iatrogenic risks of surgery are present, and include fracture and avascular necrosis50. Two papers attempt to resolve this debate, using the statistical technique of decision tree analyses. They reached opposite conclusions51, 52. Schultz advocated prophylactic pinning to maximise long-term outcomes51, whilst Kocher determined that the benefits of prophylactic pinning rarely outweighed the iatrogenic risks52.
Conclusions The current management of a SCFE is largely at the discretion and experience of the treating surgeon. Whilst SCFE is relatively rare, it is the most common hip disease of adolescence and may have devastating consequences. It is therefore difficult to defend the lack of high quality studies, and absence of randomised clinical trials.
The British Orthopaedic Surgery Surveillance (BOSS) Study is a recently established NIHRfunded nationwide prospective study of rare orthopaedic disease, beginning with new cases of SCFE and Perthes’ disease. Coordinated efforts for rare disease research have revolutionised specialties such as children’s oncology, and the desire is for orthopaedic surgeons to emulate this success with collaboration. Almost all hospitals in the UK treating SCFE are participating and data collection is underway (www.BOSS.surgery). n Daniel Perry is a consultant paediatric orthopaedic surgeon at Alder Hey Hospital in Liverpool. He is an NIHR Clinician Scientist and Senior Lecturer at the University of Liverpool. He has an academic interest in epidemiology and clinical trials relating to rare diseases. Daniel is the chief investigator for the British Orthopaedic Surgery Surveillance (BOSS) Study.
Correspondence Email: danperry@liverpool.ac.uk
References References can be found online at www.boa.ac.uk/publications/ JTO or by scanning the QR Code.
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© 2016 British Orthopaedic Association
How I Do… a Retrograde Femoral Nailing Paul Fearon Should closed reduction be unsuccessful, a half pin inserted into the proximal fracture fragment, can be attached to T-handle aids. The half pin can then be used to manipulate the fragment and assist reduction (Figure 3). It is worth drilling a pilot hole into which to insert the half pin. Once the wire tip has been advanced to the level of the lesser trochanter sequential reaming allows insertion of an appropriately sized nail.
The keys to efficient retrograde femoral nailing are in the setup and reduction.
Theatre Set-up We prefer a radiolucent operating table with an appropriately sized bolster under the distal femur. A sandbag under the ipsilateral hip also helps control rotation (Figure 1). This setup also works well for bilateral femoral nailings in the polytrauma setting. The image intensifier is positioned on the opposite side to the injured limb with the monitor placed so as to be clearly visible to both the operating surgeon and their assistant. Radiographic images are obtained prior to draping the patient to confirm satisfactory radiographic access intraoperatively. An oblique lateral
Figure 1
of the proximal femur can be helpful. Positioning, as shown in Figure 2, helps avoid interference from the contralateral femur. We have the following kit in theatre: • A retrograde nailing set; • A reaming set; • A minimally invasive soft tissue spreader; • Half pins and a universal T-handle to assist reduction.
Figure 2
Next a cannulated drill is passed over the wire and used to open the femoral canal. This drill is then exchanged for the ball tipped wire. The wire is inserted through the soft tissue guide to the level of the fracture. Traction on the lower leg combined with rotation of the T-handle will hopefully allow the end of the ball-tipped wire to engage the proximal bony fragment.
Distal locking is jig based. Proximally we recommend using a soft tissue spreader for locking (Figure 4). The spreader helps with access for drilling, measuring and bolt insertion, whilst minimising soft tissue trauma. n Paul Fearon is a Consultant Orthopaedic Trauma Surgeon based at RVI Newcastle. He trained in Belfast, Scotland, NE England and North America.
Reduction Before knife to skin ensure that the equipment is set out in the order you plan to use it in. Ensure that the ball tipped guide wire end is pre-bent and mounted in the universal T-handle.
Paul Fearon
Either a medial parapatellar or a patella tendon splitting approach is used. The trochar with a threaded guide wire, within its soft tissue protector, is inserted into the knee and the entry point confirmed using both AP and lateral x-ray images. The guide wire is then advance along the femoral canal under radiological control.
Figure 3
Figure 4
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In Memoriam
Lady Jill Charnley
26th September 1930 – 8th March 2016
Lady Jill Charnley
Jill Heaver was born in Gravesend in 1930. Evacuated in the Blitz to South Wales both she and her brother Don developed a lifelong passion for music, gardens and horticulture. Returning to London, Jill became the PA to Sir Norman Joseph, the Chief Executive of Joe Lyons. On a skiing holiday in 1958 in St Moritz she sustained a fracture and was advised by one John Charnley, a fanatical skier and confirmed bachelor who happened to be in the same resort. A whirlwind romance ensued and they were married three months later. Jill, an elegant fun loving hostess and an excellent cook, was ideal for the stream of visitors seeking knowledge in total hip replacement at Wrightington Hospital. At the time of the Teflon disaster she was
Charnley’s rock and comfort and sustained him at his lowest point. Many say that it was her steadying influence that allowed him to go on and develop the successful LFA in the late 60s. All residents and their children were invited to their beautiful home and garden at Birchwood twice a year and became members of the Charnley extended family. The Low Friction Society was formed in 1974 and friendships developed which have lasted a lifetime. In 1982 John Charnley died tragically young. Jill was determined that his last project should be completed to show that there was integration at the bone cement interphase in successful hip arthroplasty. Over 70 specimens were
analysed to prove the point. The John Charnley Trust was born and continues having given nearly £2 million for research, grants and scholarships for committed orthopaedic surgeons to visit centres of excellence around the world. Her interest in Wrightington never faltered and she was invited to cut the first sod for Phase One of the new hospital just two years ago. Over the last 18 months she became involved in the development of the new Research and Teaching Institution at the hospital which hopefully will be signed off this April. Her legacy lives on. She died at home surrounded by her loving family, Tristram and Het.
Remember them fondly It is with great sadness that we report the passing of the following members. Our thoughts are with their families and friends at this time. Allen S Baker M Heywood-Waddington Colin Lilford
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Tel: + 44 (0)1382 383400 Email: cscbookings@dundee.ac.uk Web: www.cuschieri.dundee.ac.uk
Firstkind Ltd, UK 0845 2222 921 geko.support@ firstkindmedical.com www.gekodevices.com @gekorecovery
Volume 04 / Issue 02 / June 2016
boa.ac.uk
Page 60
Imprint
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JTO Editorial Team l l l l l
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References 1. Data on file -CORAIL PINACLE Unit Sales 2015, DePuy Synthes Companies of Johnson & Johnson 2. Orthopaedic Data Evaluation Panel. ODEP product ratings. Available from www.odep.org.uk [Accessed 01/10/2015]. 3. Hallan G, Lie SA, Furnes O, Engesaeter LB, Vollset SE, Havelin L. Medium and long-term performance of 11 516 uncemented primary femoral stems from the Norwegian arthroplasty register. J. Bone Joint Surg. 2007;89-B:1574-1580. 4. Chatelet J-C. Survivorship in 120 consecutive cases at 12 years. Rev Chir Orthop Reparatrice Appar Mot. 2004;90(7):628-635. 5. Bedard N, Callaghan J, Stefl M, Williams T, Liu S, Goetz D. Fixation and Wear with Contemporary Acetabular Components and Cross-Linked Polyethylene at 10-Year Follow-Up. Journal of Arthroplasty. 2014; 29: 1961-1969. 6. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man, 12th Annual Report, 2015. Table 3.10. Available from: www.njrreports.org.uk