The journal OF the British Orthopaedic Association Volume 03 / Issue 02 / June 2015 boa.ac.uk
Inside
Read the News and Updates section for the latest from the BOA and beyond
Our Features section includes articles focussing on research and commissioning
For the latest updates on our clinical issues, see our Peer-Reviewed Articles; the focus of this issue is hip surgery
News & Updates ––– Pages 02-15
Features ––– Pages 16-40
Peer-Reviewed Articles ––– Pages 42-52
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JTO News and Updates
From the Editor
Contents
Ian Winson, BOA Vice President Elect A lot has happened since the last issue of JTO was published, most importantly the official publication of the Getting it Right First Time report. There has also been something in the news about a general election but Colin Howie will touch on this in his Presidential article over the page. This issue touches on many interesting subjects. Our Vice President, Tim Wilton’s commissioning article and observations on the importance of viewing your own data gives focus to an important part of practice (page 26). There is a three-pronged focus on research with research priority setting and the James Lind Alliance (page 22), Major Trauma trials and their evolution (page 32) and finally how the NJR supports research (page 24). The BOTA President’s, co-authored article on training in Europe gives food for thought. Medico-Legal issues include the second part of the Code of Practice (page 38) and the odd problem of whiplash in children (page 36). What do you see on the front cover? It’s subject to your interpretation. The focus on the PeerReviewed section is Hips. Our Guest Editor for this section was Andrew Hamer. You will find a general interest piece on the rise of big data; a scientific
article on VTE and a controversial piece about metal on metal from page 42. Our regular “How I Do…” piece submitted by a member of the Orthopaedic Trauma Society (OTS) follows these and focuses on the use of blocking wires to nail proximal tibial fractures (page 52). We also pay tribute to colleagues, including two taken from us at an untimely age – J Tulloch Brown, John Goodall, Gamada Ayana and Andrew Sprowson (pages 54-55). Sadly, since the compilation of this issue, we have lost our colleagues Tony Fogg, Steve Copeland, Frank Beddow and Robert Robins. Our thoughts are with their family and friends at this sad time. They will feature in the “In Memoriam” section in the September issue. We are receiving increasing numbers of letters and responses to the controversies and issues raised. Keep them coming!
JTO News and Updates
02–15
JTO Features
16–40
High Intensity Intermittent Exercise My Locum SHO Experience: Never Again! BOA Ambassador to the 34th Hong Kong Orthopaedic Association Annual Congress 15-16 Nov 2014 Setting Priorities for Research in Orthopaedics within the UK: The James Lind Alliance How does the National Joint Registry Support Research? Commissioning SOS: Can we use it to Save Our Service? Two Years in Malawi and out of Training Orthopaedic Trauma Surgeons in the UK delivering world-leading clinical research – that’s a joke! How to Train a Surgeon Personal injury claims for children suffering back and neck pain following minor to moderate road traffic accidents: a personal view Code of Practice for Orthopaedic Surgeons Preparing Reports in Personal Injury and other Cases (Part 2)
16 18 20 22 24 26 30 32 34 36 38
JTO Peer-Reviewed Articles 42–52
Metal Exposure after Hip Replacement and the Risks of Systemic Toxicity The rates of Thromboembolic events in patients undergoing elective hip and knee arthroplasty before and one year after the introduction of the NICE guidelines The Rise of Big Data and Can it be Used to Compare International Healthcare in Orthopaedic Surgery? How I... Use Blocking Wires to Nail Proximal Tibial Fractures
In Memoriam General information and instructions for authors
42
44 48 52
54–55 56
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JTO News and Updates
Physician, heal thyself Prof Colin Howie, BOA President
As ever the pre-election pollsters have proven woefully wrong. We have a majority government (albeit of a different hue in Scotland!). Ironically this apparent medium term stability is unlikely to lead to an overall change in the structure of healthcare delivery, though we can be sure that there will be a significant change in emphasis. Simon Stevens has a five year plan which presents major challenges and opportunities and is likely to be the template for the future.
Already Manchester is planning a devolved and integrated healthcare service, beyond that which exists in Scotland. We have strong orthopaedic representation and co-operation at the highest level in Manchester thanks to clinical engagement. We may well see considerable consolidation amongst CCGs.
Prof Colin Howie
Will these changes involve trauma and orthopaedics? Without doubt. Money is still tight and there will continue to be pressure on all budgets. MSK has a large slice of the pie which many of our medical colleagues see as discretionary. To date where orthopaedics has engaged constructively with the CCGs we have been able to influence system development. The basic fundamentals remain the same in all systems; treating the right patient at the right time with the right procedure will produce good results. We must ensure that
the majority of our care continues to be dealt with efficiently and well. Orthopaedics and trauma have the best cost effective outcomes in modern medicine, though we do not publicise this enough. The challenge for us is to ensure we do not over-treat patients (or over-investigate leading to overtreatment) thereby diminishing the cost effectiveness and the reputation of our specialty, allowing others the opportunity to criticise. Most importantly, we must remain engaged with the CCGs. While the BOA will support this, we cannot be everywhere and we need you to become engaged via local clinical networks. Many once popular specialties are having problems recruiting (Medicine, Emergency Medicine, General Practice to name a few) even trauma and orthopaedics is noticing a reduction in applications for training. In parallel an
increasing number of consultant jobs remain unfilled - anecdotally there has been an upsurge in numbers of consultants and trainees leaving the NHS to work abroad. Financial imperatives may drive this, however, most people come into medicine because of the intrinsic personal satisfaction when a patient responds to treatment and is grateful. The introduction of increasingly complex contracts for consultants in combination with regimented working patterns to comply with EU employment law have contributed to a fragmentation of the patient’s care pathway that has eroded that intrinsic satisfaction. In addition, many hospital jobs have become 24/7 throughout a career, which may well extend till 70 years of age. The prospect of being up at 2am in your late 50s dealing with routine problems is unattractive to the highly motivated individual.
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So we have a muddle on our hands and, despite some notable exceptions, few have covered themselves in glory. A widely held perception is that: • NHS management’s default position is to knee jerk into short term political fixes creating long term system problems in the process • A uniquely British insistence on EU compliance by employers has resulted in a culture of slavish adherence • The largest professional medical association has tended to focus on salary alone - it has ignored vocation • Specialty associations have sometimes preferred to concentrate on the technicalities of delivery rather than the big picture • Overseers of training have frequently acquiesced to change without insisting on the enabling resources.
Although done, no doubt, with the best of intentions this has led to the unintended consequence of devaluing the intrinsic satisfaction of being a doctor. The result is a reduction in the numbers coming into and staying with the profession: a career in medicine in general and surgery in particular is seen as unattractive and unsustainable throughout a normal working life. We have allowed medicine to be commoditised to the detriment of our patients and ourselves. We have medicalised care such that no presentation goes uninvestigated or untreated. The challenge for us all is to reverse this and ensure that we return to the values and mores of trusted professionals while at the same time providing a safe and cost efficient service.
The BOA has already started the process through active clinical leadership of a broad spectrum of issues across the NHS in the UK where our stock is high: we can and will make a difference. We are also in candid discussion with the BMA, using our position within the Federation of Surgical Specialty Associations to raise the bar of surgical debate, and are proactively involved with the Colleges in progressing the training and education agenda.
We encourage all of you to work with us by sharing your insights and knowledge, especially for those experiencing difficulties with individual Trusts or Health Boards, and spreading the word to colleagues outside the BOA: the ways, ends and means of meeting the challenges ahead lie in our own hands.
Here is the rub, while the BOA can and has achieved a lot leading and influencing from the front, the collective contribution of the profession – every one of you – adds much more power to our elbow. Having spoken and met many of you at recent specialist society meetings I know the desire is there to bring about change.
BOA Membership UKITE
Since 2014 UKITE has been integrated into the BOA membership. UKITE is a national, online examination providing immediate results to trainees with similar formatted questions based on the UK Trauma and Orthopaedic curriculum. UKITE has been an annual event in the post-graduate orthopaedic calendar since 2007. Currently it hosts a question bank of around 11,500 MCQs and EMQs providing a powerful educational resource with high quality, relevant and curriculum-based questions. This year UKITE will run from 4th-11th of December. For more information on the 2015 UKITE dates please visit the BOA website www.boa.ac.uk/training-education/ukite.
Save the date!
BOA 2016 Travelling Fellowships
Opening Soon! Keep an eye on the BOA website for confirmed dates www.boa.ac.uk/training-education/ travelling-fellowships
BOA Instructional Course 2016 9th-10th January, Manchester Conference Centre Registration opens early July 2015 www.boa.ac.uk/events/instructional-course
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JTO News and Updates
Registry and quality outcomes round-up from the BOA Quality Outcomes updates • BSCOS (British Society for Children’s Orthopaedic Surgery) has launched its new registry collecting data for the following pathways: Supracondylar Fracture of the Humerus, Slipped Capital Femoral Epiphysis and Ponseti Management of Clubfoot. The registry is open only to BSCOS members, and the BOA encourages participation. For more details, visit http://bscos. org.uk/registry/index.html. • The UK Knee Osteotomy Registry, which started data collection in November, is well underway, with 200 cases recorded so far. If you or your unit haven’t yet got involved you can get in touch via www.ukkor.co.uk.
• For BOFAS (British Orthopaedic Foot and Ankle Society), a pilot has commenced collecting data pertaining to 1st MTPJ fusion and ankle fusion, and more information can be found at www.bofas.org.uk. • At the OTS annual meeting in March, it was agreed that TARN will be used for collecting data on pelvic and acetabular fractures across the UK. Some amendments to the current data set will need to be made and in each region a trauma database network lead will be identified to help coordinate the running of the database. The BOA’s Quality Outcomes workstream is continuing to work with and support these and the other emerging registries and audits (British Spine Registry,
An example section of an enhanced hospital-level NJR dashboard © HQIP
the National Ligament Registry (NLR), the Non-Arthroplasty Hip Register (NAHR) and the BSSH Audit) as they are becoming established. For more information see www.boa.ac.uk/pro-practice/ boa-quality-outcomes-project.
NJR updates • The National Joint Registry (NJR) has published enhanced hospital-level dashboards covering a wider range of metrics than previously was available, including patient reported outcomes, patient characteristics, revision rates and data quality. Surgeon level dashboards are unchanged. For more details, visit http:// njrsurgeonhospitalprofile.org.uk.
• The NJR is also running a data quality initiative at present, including data validation at a local level. For more information contact your NJR regional contacts or enquiries@njrcentre.org.uk. The BOA supports this initiative and urges all orthopaedic team members to contribute. • The provisional date for this year’s round of the consultant outcome publication initiative to go live for orthopaedics is 30th November. The BOA will be continuing to work with the NJR on this and will be keeping our members informed of the arrangements.
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JTO News and Updates
BOA Latest News The Value of Orthopaedic Surgery The BOA is undertaking an initiative to gather together evidence demonstrating the value of Orthopaedic Surgery. The purpose of this initiative is to create a narrative with which to influence national health leaders, commissioners, and the general public. The cost-effectiveness of Orthopaedic Surgery is a key selling point the BOA is planning to focus on and we have identified a number of exciting statistics to support this case, such as: • The estimated 10-year cost per QALY for hip replacement surgery is £4,288. • This means hip surgery costs less than £10 a week for sustained pain relief. • Where the replacement hip joint lasts 15 years without revision, the QALY cost is only £7.50 a week. • Furthermore, based on the 10-year QALY cost estimate, hip replacement surgery is approximately 7 times more cost effective than drugs priced at the threshold NICE use for Health Technology Assessment. For more information, please contact policy@boa.ac.uk.
GIRFT - A national review of adult elective orthopaedic services in England Led by Professor Tim Briggs the BOA’s GIRFT Report was published in March with the NHS England’s agreement. The report reviews current practices and outcomes of NHS hospitals providing orthopaedic surgery in England, to identify and quantify variation in clinical outcomes, processes, patient experience, patient pathways, network arrangements, financial impacts and waiting times. The report builds on Prof Briggs’ original research in 2012 which suggested ways in which extensive savings and improvements could be made in elective orthopaedics by hospitals to ensure continuing high quality care and access for patients within the financial constraints of the NHS. NHS England funded the GIRFT pilot as a national professional pilot across England. The project was hosted on behalf of the BOA, at the Royal National Orthopaedic Hospital (RNOH) in Stanmore. The full report and supporting documents can be downloaded at www.boa.ac.uk/pro-practice/getting-itright-first-time.
BOA Regional Advisers and Clinical Champions
BOA Clinical Leaders Programme 2015-2016
On 1st June the BOA held an event in Birmingham to support our Regional Advisers and Clinical Champions to engage with CCGs and influence local commissioning decisions.
Earlier this year, the BOA launched a new leadership programme: BOA Clinical Leaders Programme 2015-2016.
The event provided an overview of MSK Commissioning; a briefing on BOA Commissioning Guidance; examples of how T&O surgeons have successfully influenced commissioning and an interactive engagement workshop detailing how to influence commissioners. There will be a further, similar event, open to all members at the BOA Congress in September. For further information on how you can be part of the BOA’s efforts to influence commissioning, please contact policy@boa.ac.uk.
The programme aims to develop current and future orthopaedic consultant leadership capability for the NHS. It is now open to senior trainees, SAS doctors and new consultants (all those who have become fellows in the last two years). Details about the programme, its application process and access to the online application form can be found on the BOA website or by contacting policy@boa.ac.uk.
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Consultant Outcome Publication The BOA recently responded to a consultation regarding Consultant Outcome Publication, submitted jointly with BOFAS, BASK, BESS and BHS, and attended a workshop meeting reviewing the 2014 round of publication. The consultation response submitted is available online bit.ly/1Qp8udj and you can read the consultation document to which we were responding bit.ly/1JRH6np (please note this document link is confidential to BOA members and not for further circulation). The BOA continues to actively engage on this initiative on behalf of our members, and you can read more about this on our revamped web pages bit.ly/1Qp8Jow. Early conversations about the 2015 round of publication have begun, and we will continue to keep members informed on the progress of these.
Chavasse
Report Funding
The government has committed £75 million of LIBOR fines over the next five years to support military charities and other good causes. The Chavasse Report has been awarded £2 million to pilot the implementation of the recommendations in the report for a network of NHS hospital based rehabilitation services for veterans and reservists.
Orthopodcast
Investigating
CCG Triage
Matt Costa revisits the DRAFFT trial six months on from last year’s Orthopodcast, by discussing some of the lessons learned from the research process and the outcomes. This builds upon previous Orthopodcasts with a new screencast style. You can view this at www.boa.ac.uk/ orthopodcast/episode-5the-drafft-study. We would be interested to hear your views on whether you prefer the podcast or screencast format.
In order to investigate the use of Triage services for patients with orthopaedic symptoms, the BOA has collected data on CCG’s use of triage services and has produced an internal report summarising findings.
The Orthopodcast series can be found at www.boa.ac.uk/training-education/orthopodcasts.
For more information, please contact policy@boa.ac.uk.
Primary Care Workforce Commission The BOA recently responded to the Primary Care Workforce Commission’s call for evidence on primary care models and training needs. The work of the Commission will inform priorities for HEE investment in education and training to deliver a primary care workforce that is fit for purpose, flexible and is able to respond to new models of care. The BOA response argued for greater integration between primary care and Orthopaedics, highlighting the Aberdeen integrated back care pathway as an excellent example of integrated working between primary and secondary care. The response also highlighted the need for greater training in MSK within the primary care workforce and cited evidence from: • The BOA’s Undergraduate syllabus for Trauma and Orthopaedic Surgery • Getting it Right First Time • Restoring Your Mobility • The BOA’s NICE-Accredited Commissioning Guidance documents For more information, please contact policy@boa.ac.uk.
The research has highlighted significant variation in practice across the country, as well as giving a forwardview of upcoming MSK Commissioning Activity. The project will now collect further data to assess the impact of triage on service delivery.
MSK Commissioning In One Place To ensure that members can easily access information about all BOA Commissioning initiatives and documents, all existing resources related to Commissioning have been collated into one section of our website www.boa.ac.uk/propractice/msk-commissioning. This will allow members to track commissioning developments, view the BOA’s Commissioning Guidance and tell the BOA about commissioning issues in your area. Members will also be able to find details of their Regional Advisers and Clinical Champions to help influence local commissioning.
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JTO News and Updates
BOA Annual Congress 2015 15th-18th September ACC Liverpool The BOA Congress 2015 is back to the traditional four day programme. The theme for this year is ‘Professionalism and Responsibility’ and will be held at the ACC Liverpool; a worldclass facility sitting at the heart of the waterfront. The 2015 Congress programme is rapidly taking shape and includes a range of broader professional issues, plenaries and clinical sessions. Key highlights include: • Navigating the NHS and Health and Social Care Landscape - this session will explore the complexity of the NHS and health care systems within the UK, comparing strengths and weaknesses of different models. Invited speakers include representatives from NHS England, the Welsh NSAG, NIROTC and the President of the British Orthopaedic Directors Society. • T&O Surgery after the General Election - focussing on the political landscape for the next 5 years and potential implementations on the health industry with debate from the President of the Royal College of Surgeons, Circle and ABHI.
• Mapping a way forward for T&O Commissioning - with speakers invited from NHS England as well as a Clinical Commissioning Group. This session will provide an overview of the commissioning process, summarising the BOA’s work and exploring how best to work and integrate with commissioners. • Managing Data Responsibly Dame Fiona Caldicott will deliver a lecture followed by a panel debate and Q&A session with Prof Martyn Porter (NJR Medical Director and orthopaedic surgeon), Andy Lewis (General Medical Council), Pida Ripley (patient), Mr Paul Halliwell (BOFAS registry and orthopaedic surgeon), Mr Phil Johnston (Caldicott Guardian and orthopaedic surgeon) and Cathy Hassell (NHS England Quality Programmes Team). This panel session will cover a wide range of issues, from ‘what do patients expect of a registry?’, to data protection and governance for surgeons and trusts.
The BOA Congress 2015 Guest Lecturers include: President’s Guest Lecture Stefan Lohmander Senior Professor in Orthopaedic Surgery at the Department of Clinical Sciences at Lund University, Sweden.
Howard Steel Lecture James Ketchell Serial adventurer, motivational speaker and Scouting ambassador.
• Confirmed courses include Good Clinical Practice (GCP) training, Non-Technical Skills and an all day clinical examination course.
The BOA will also be holding a Robert Jones golf day on Monday 14th September at the Caldy Golf Club, Wirral. The host for the golf outing is Mr John Ireland. Please book your place through the Congress website – congress.boa.ac.uk.
View the Congress website at congress.boa.ac.uk and download the provisional programme.
Liverpool is easily accessible from around the UK, view the travel options on the Congress website.
The BOA Congress 2015 will be held at the ACC Liverpool; a world-class facility sitting at the heart of the waterfront
Once you have registered for the Congress please book your accommodation through TSC Hotels and Venues, the official Congress hotel booking agency. We hope you will join us for hot topic discussion and to ensure that we continue to raise standards, and encourage the highest levels of Professionalism and Responsibility.
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My Travelling Fellowship Arpit Jariwala
I was honoured to be the recipient of the prestigious BOA Travelling Fellowship Award 2014 which gave me the opportunity to visit centres of excellence for upper
limb surgery and research in North America in September 2014. I first visited Professor Mohit Bhandari, the Canada Research
At Mayo with Professor Bernard Murray, Professor Cofield, Professor Steinmann and Professor Sanchez-Sotelo
Chair in Musculoskeletal Trauma and Surgical Outcomes at the McMaster’s University, Hamilton to gain insight of developing and running an extremely productive research unit. My next stop was London, Ontario to meet Professor Graham King, Dr Ken Faber and Dr George Athwal at the St Joseph’s Healthcare Centre (SJHC). They had lined up cases of radial shortening for Keinbock’s disease, ulnar osteotomy for impingement and an arthroscopic elbow debridement and in-situ ulnar release for elbow arthritis for me. I also got the opportunity to observe a bilateral ‘terrible triad’ of elbow in a young motor cross racer being reconstructed. This was a pure master class in elbow trauma. My last stop was the world renowned MAYO Clinic, Rochester, Minnesota to meet Professor Scott Steinmann and
Professor Shawn O’Driscoll. They had called for many interesting and complex upper limb cases including an elbow arthroscopy in a patient who had a tendo-achilles allograft insertion for symptomatic traumatic radial head deformity in childhood. In the clinics I saw amongst many cases, a case of 12 year follow-up of partial radial head replacement. Prof O’Driscoll shared his thinking on neurogenic contractures of elbow and heterotrophic ossification and the rationale behind the thought. While at MAYO clinic I also met Professor Kai-Nan An (Head of Orthopaedic Clinical Research) and Professor Kenton Kaufman (Head of Biomechanical Studies). Finally, I was invited to deliver a talk on my work ‘Kinematic analysis of humeral head resurfacing’ to the orthopaedic team in the MAYO clinic during the monthly orthopaedic meeting.
Newcastle Surgical Training Centre delivers over 150 advanced training courses from regional, national and international surgeons representing multi specialties. Collaboration with national and international faculty drives a greater understanding of surgical techniques delivering improved patient care.
In partnership with:
For full details and registration information visit www.nstcsurg.org or contact: Lorraine Waugh Tel: (+44) 191 24 48913 Email: lorraine.waugh@nuth.nhs.uk
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JTO News and Updates
BHS Annual Scientific Meeting 2015
440 surgeons, arthroplasty care practitioners and others attended the 2015 British Hip Society Annual Scientific Meeting in London, in March and enjoyed a “rammed” programme of podium and poster presentations, encompassing two long days and most aspects of hip surgery. Free Paper sessions interdigitated with Topics in Focus and both were punctuated by lively debate. Podium presentations covered issues ranging from hip fractures and non-arthroplasty hip surgery to metal-on-metal follow-up and revision surgery and included a joint session with our academic colleagues in the British Orthopaedic Research Society.
The BHS Meeting
BASK Spring Meeting 2015
The Non-Arthroplasty Hip Register is maturing nicely and The Emerging Hip Surgeons Forum offered newly appointed consultants and senior trainees a “leg up” on a number of aspects of hip surgery. The Topics in Focus sessions enabled some of our most experienced colleagues to share their knowledge
The British Association for Surgery of the Knee meeting this year received over 220 abstracts; the executive scored these blind and this resulted in 60 excellent free papers in themed sessions, presented by both trainees and consultants. For the first time at a BASK meeting we introduced a medico-legal session in the form of a mock trial. A real medical negligence case, details anonymised of course, was conducted with the assistance of barristers, Mr William Poole and Mr Matthew Maudsley, both from St John’s Chambers in Manchester. The judge was Sean Duncan, a retired circuit judge. Our two expert witnesses were Roger Smith representing the defendant and Professor John Fairclough providing expert evidence for the claimant.
Hermann Mayr presenting ‘The Stiff Knee’ lecture
Our Lorden Trickey guest lecturer was Prof Hermann Mayr from Munich, who gave an erudite address on “The Stiff Knee” - perhaps one of the most difficult clinical challenges that knee surgeons face.
of the changing paradigms of prevention, diagnosis and treatment of the infected hip replacement, the complexities and options for acetabular reconstructive surgery and surgeon level outcome data, with the latter stimulating some particularly heartfelt discussion. We were treated to a masterful and truly reflective Presidential Lecture by Dr David Lewallan from the MAYO clinic, USA, entitled “New Technology in Hip Surgery: Cures, Casualties and Current Challenges”. A great meeting! Particular thanks must go to Andrew Manktelow who put the programme together, John Skinner for his exceptional leadership of the BHS throughout the year and Steve Jones who co-ordinates everything else and to John Timperley who leaves the BHS executive after many accomplished years. Next year’s meeting will be in Norwich (16th-18th March 2016) and you are all invited!
There was an excellent session on registries. Martyn Porter presented on the NJR. There was also a very valuable contribution from Sean O’Leary who has done magnificent work in establishing the National Ligament registry (NLR). The UK Knee Osteotomy Register (UKKOR) is an even younger creation, presented by David Elson. Finally, there was an excellent session on chondrocyte surgery. A discussion on the new NICE guidance which suggests that the procedure lacks scientific evidence and that this surgery cannot be recommended for routine use on the NHS. BASK have responded to NICE appealing their decision. The outcome is awaited. Many thanks to all who attended in Telford and we look forward to an equally successful spring meeting next year, which will run from 30th-31st March 2016 at the ACC in Liverpool.
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BSCOS – Liverpool 12th-13th March 2015 The British Society for Children’s Orthopaedic Surgery held its annual meeting on Liverpool’s waterfront this year. Mr Colin E. Bruce hosted the meeting with the local Alder Hey Children’s Hospital team in the Rum Warehouse conference facility at the Titanic Hotel, set in a quirky mix of new and old architecture in the first stage redevelopment of the grade II listed Stanley Dock complex, the largest brick built warehouse in the world.
BSCOS President Mr Aresh Hashemi-Nejad welcomes Professor Toshio Kitano of Japan to BSCOS Liverpool 2015
2nd Annual OTS Meeting 19th-20th March 2015
The meeting hosted almost 200 delegates who enjoyed an update on the management of paediatric spine deformity delivered by keynote speakers Mr David Marks (Birmingham), Mr Neil Davidson (Liverpool & Oswestry) and Mr Mike Grevitt (Nottingham), with an update covering the management of cerebral palsy, delivered by Dr Gunnar Hagglund (Lund, Sweden), Prof. Reinald Brunnar (Basle,
Trauma surgeons from around the country gathered in Coventry to hear updates, research ideas, theories and debates and enjoy the facilities of the new Radcliffe building on the University of Warwick campus. OTS were fortunate to have Norbert Haas give the guest lecture: “Observed evolution of trauma care 1966-2014”. As a breath-taking solar eclipse was witnessed by millions, a much smaller group of trauma surgeons witnessed Bob Handley present the unifying theory of bone healing. A theory that has resulted in a change in the way non unions are managed.
Prof Matt Costa presenting at the OTS meeting
Pete Hull from Cambridge presented K-FORT; a new multicentre trial, looking at distal femoral locking plates vs distal femoral replacement.
Switzerland) and Mr Martin Gough (London). Professor Toshio Kitano (IwamotoFujii Ambassador) representing the Japanese Paediatric Orthopaedic Society attended the meeting to deliver a special presentation “The Spectrum and Management of Children’s Hip Disorders in Japan”, comparing and contrasting management across cultures. The BJJ donated a £500 prize for the best free paper “Manipulation and reduction of forearm and distal radial fractures in children in the emergency department using entonox and intranasal diamorphine: A 2.5 year study”, presented by Tom Kurian (Nottingham). The paper also won presentation space at EPOS in Marseille 15th-18th April 2015. Ms Jo Hicks will host the next meeting of the Society with the Stoke Mandeville team from 10th-11th March 2016.
“The Dragons Den” heard a number of suggestions for research projects to go forward ranging from pre-hospital delivery of antibiotics for open fractures, treatment of the unstable lateral compression injuries of the pelvis to resuscitative blood transfusion in the fracture neck of femur population. The consequences of the publication of the DRAFFT study were presented, ending with Matt Costa introducing DRAFFT 2 - MUA and cast vs MUA and wires. President, Nigel Rossiter, chaired the final session informing the audience of the OTS’s achievements of the past year and hopes for the following year under the presidency of Bob Handley. After a successful meeting this year, the next OTS meeting will be back in Coventry in 2016.
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JTO News and Updates
BLRS Annual Meeting March 2015 As Mark Twain said – “It’s not the size of the dog in the fight; it’s the size of the fight in the dog that matters”. Though making up one of the smallest UK sub-specialist societies, Limb Reconstruction surgeons can rightly be described as punching above their weight, taking on cases when often limb ablation is the only alternative. The BLRS AGM is one opportunity for “frame geeks” to network with like-minded colleagues, to consider newer techniques and to listen to pioneers in the field. The 2015 AGM was hosted by Deepa Bose, Consultant Orthopaedic Surgeon at QEH, Birmingham. Deepa arranged a fantastic conference to address
key issues around the practice of limb reconstruction within the NHS. In addition, it was another opportunity for the society to discuss the challenge of monitoring outcomes nationwide through the BLRS Registry and the debate was framed by a keynote address from Fergal Monsell (BLRS President Emeritus). Birmingham boasts of particular expertise in combat trauma and this added a distinctive flavour to the meeting with talks from health professionals treating soldiers. There were insightful talks on managing pain in limb trauma reconstruction, the sequelae of blast injuries, amputation and prosthetics.
BSS Meeting 21st-23rd April Sheffield
Bathed in Birmingham spring sunshine, delegates take in the solar eclipse
Dror Paley, Florida, USA, was a visiting speaker for the event. He enjoys a pre-eminence in the field of limb reconstruction and he shared his experience with intra-medullary lengthening and congenital limb deficiencies. There were many other memorable instructional lectures from other speakers on topics including Chronic Osteomyelitis and the use of plate fixation as an adjunct to distraction osteogenesis.
Deepa surpassed all previous hosts by arranging a solar eclipse on the 20th March, the second day of the conference! A timely coffee break was arranged for delegates to view this rare celestial phenomenon. It added to a memorable meeting and will have whetted the appetite of many delegates to attend the next annual meeting to be held jointly with BAPRAS in Liverpool on the 16th-18th March 2016.
Fabulous sunshine greeted over 200 delegates to this year’s British Scoliosis Society (BSS) meeting at City Hall in Sheffield.
was entitled “Shilla guided growth for EOS” which presented the novel technique from inception to present day.
For the first time, a combined scientific meeting was organised combining the BSS, Neuromonitoring UK and National Paediatric spinal anaesthesia groups.
A panel discussion on MedicoLegal aspects of deformity surgery was well received, as was an overview of the complexities of adult spinal deformity surgery.
International faculty included Prof Richard McCarthy, past President of the SRS, Dr Tod Sloan, and Dr Francesco Sala.
During the audit and governance session a society first was achieved with discussion of unit compliance with the National audit program via the British Spine Registry.
The three day meeting opened with an instructional course for future deformity surgeons with practical workshops presided over by a large national faculty. A parallel session organised and run by the societies’ AHP division commenced with a practical session on EDF casting.
The local hosts and international speakers at the Black Tie Dinner
Scientific sessions included 35 free papers, invited lectures and debates. The annual Greg Houghton Lecture was given by Prof McCarthy from Arkansas and
The traditional Black Tie dinner in the stately surroundings of the Cutler’s Hall, was rounded off by the authentic sounds of a Frank Sinatra tribute. The meeting was brought to an end by the light hearted observations on the spinal world by the recently retired Mr John Webb. A good meeting was had by all, and all eyes turn to Nottingham for BritSpine in 2016.
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JTO News and Updates
Letter to the Editor Dear Sir,
Re: BOAST 11 I was deeply shocked by BOAST 11. Supracondylar fractures in children do not all require internal fixation. Closed manipulation or Dunlop traction can be used very successfully. We are in danger of increasing the belief amongst young Orthopaedic surgeons that fractures will not heal unless metal fixation is used. The message that these fractures should be internally fixed is a disastrous one for overseas trainees. The appropriate skills and operative facilities are frequently absent in many parts of the world
and often the patients cannot afford the implants and surgery. We must not forget the work of John Charnley, Watson Jones, Sarmiento and others who all showed that successful fracture management can be achieved without implants. In my visits to developing countries I see the tragic results if ORIF performed by less skilled surgeons in suboptimal conditions leading to infection, mal-union and nonunion, and often patients with huge debts. Yours faithfully, Louis Deliss FRCS Chairman, British Palawan Trust
Response from Tim Chesser – Chair of BOA Trauma Group Dear Mr Deliss, Thank you for your letter and interest in the BOAST and I am sorry it has shocked you. The BOAST is a “British” standard designed for British patients treated in the NHS and for displaced fractures. We appreciate that guidelines for less developed countries would differ but this is not the aim of our guidelines. It should also be noted that many of the current research projects the BOA membership has involvement in, challenges surgical fixation for many fractures.
Conference listing:
Organisation Conference/meeting BOOS (British Orthopaedic Oncology Society) www.boos.org.uk
Annual Meeting 12 June 2015, Oxford
BOTA (British Orthopaedic Trainees Association) www.bota.org.uk
Educational Weekend 12-14 June 2015, Chester
BESS (British Elbow and Shoulder Society) www.bess.org.uk
Annual Meeting 24-26 June 2015, Sheffield
IOS UK (Indian Orthopaedic Society) www.iosukliverpool2015.com
Annual Meeting 3-4 July 2015, Liverpool
BOA (British Orthopaedic Association) www.boa.ac.uk
Annual Congress 15-18 September 2015, Liverpool
BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk
Annual Meeting 15-16 October 2015, London
SBPR (Society for Back Pain Research) www.sbpr.info
Spring Meeting 5-6 November 2015, Bournemouth
BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk
Annual Meeting 11-13 November 2015, Guildford
OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk
Annual Meeting 20-21 January 2016, Coventry
BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk
Annual Meeting 10-11 March 2016, Aylesbury
BHS (British Hip Society) www.britishhipsociety.com
Annual Conference 16-18 March 2016, Norwich
BLRS (British Limb Reconstruction Society) www.blrs.org.uk
Annual Meeting (w/ BAPRAS) 16-18 March 2016, Liverpool
BASK (British Association for Surgery of the Knee) www.baskonline.com
Annual Conference 30-31 March 2016, Liverpool
BRITSPINE www.britspine.com
Meeting 6-8 April 2016, Nottingham
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The London Marathon 2015 We would like to say a big thank you to consultants Simon Boyle (York) and Simon West (Northampton); FY2, Matthew Chan (Bournemouth); and nurse, Rosie McSweeney (Benenden Hospital) who ran the Virgin Money London Marathon on Sunday 26th April, raising money for Joint Action (the Orthopaedic Research Appeal of the BOA). We have a limited number of Golden Bond places for the 2016 Marathon. Submit your interest for a guaranteed place with Joint Action by emailing Lauren Rich at l.rich@boa.ac.uk.
Raising money for Joint Action (the Orthopaedic Research Appeal of the BOA)
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JTO Features
High Intensity Intermittent Exercise James Brock Contributing authors: Dr Stuart Gray, Dr Gavin Langlands
Obesity is a pandemic problem leading to a higher prevalence of obesity-related disorders. Recent research has demonstrated that High Intensity Intermittent Exercise
(HIIE) could be beneficial in decreasing adiposity levels, improving endurance capacity and enhancing the actions of insulin. In addition, this has potential to be used as a rehabilitative method for patients in areas such as Orthopaedics.
Methods
James Brock
Fourteen subjects were designated either an HIIE regime of 30s (n=7) cycle sprints with a four minute recovery period or 6s (n=7) cycle sprints with thirty seconds recovery, performed over a two week period. Endurance performance was monitored using time trials and analysis of plasma samples to observe any changes in concentrations of insulin, glucose, triglyceride and Il-6.
Results After two weeks of HIIE, performance improved from the baseline endurance trial in both groups (p<0.05). Plasma levels displayed irrelevant changes from the baseline samples (p>0.05) which disagreed with the majority of other studies focusing on HIIE, that found improvements within adiposity levels and actions of insulin; therefore, more sensitive tests may be required.
Conclusion
orthopaedic rehabilitation especially when looking at the 6s protocol. James Brock studied and graduated in Medicine from Aberdeen University in 2013 with an Intercalated degree in Sports and Exercise Science. He is currently completing my Foundation Year 2 in Glasgow and will be working a CMT job in the West of Scotland in August. This is an abstract from an article on HIIE. The full article and related references can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
HIIE appears to be as beneficial in improving oxidative capacity, decreasing adipose tissue and increasing insulin sensitivity as endurance type workouts and are also more time efficient. Therefore, HIIE could be helpful for improving patient’s
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Intramedullary Nailing: A Comprehensive Guide Author/s: Rommens, P M; Hessmann, M H ISBN: 9781447166115 Publication Date: 04/02/15 Price: £135.00
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Advertiserâ&#x20AC;&#x2122;s Content
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JTO Features
My Locum SHO Experience: Never Again! Andrew James
I am currently a ST8, and in a moment of madness, I agreed to do a locum shift in Trauma and Orthopaedics. The shift started in the seminar room for the formal handover from the daytime SHO just before 5pm. He handed over four patients that had presented to A&E that afternoon, and he had spent the whole afternoon with one patient.
Consequently, my first few hours on call were spent clearing the backlog. This involved a discussion with A&E regarding conscious sedation for a displaced distal radial fracture as the patient had median nerve symptoms and had not even been splinted as the locum A&E Consultant had decreed that it was “too bad” to reduce and needed to go to theatre. Of course his shift had finished. After discussion with another A&E Consultant, which inevitably lead to a complaint about waiting times, I thought we were about to proceed to reduction, when I made the mistake of asking for fentanyl, which lead to another host of problems!
Andrew James
I have found myself using the phrase “It wasn’t like that in my day!” with increasing frequency. The “SHO” rota in this hospital is one of the few that is still an on-call rota with current core trainees’ experience primarily based on shift patterns. I believe
that this has led to a “triage” mentality. The ethos of handing over as few tasks as possible to your colleague has certainly gone. Individual Consultant teams have disappeared completely. This one night on-call acts as a microcosm of the current problems with medical staffing in the NHS. What can we do about it? Increase the role of specialty doctors to provide more service provision? Embrace more on-call rotas to maintain continuity and re-think the European Working Time Directive? Unfortunately, these developments would require appropriate funding.
staffing at a junior level, and much as those of us who are capable of recalling “the good old days” would like to think they weren’t that good and they are not likely to return. The solution to staffing problems are not endless locums but change in both working and training practice and needs on going thought and almost certainly a more wide ranging change in Practice. There is a need for post reconfiguration. We need to bring to the public arena that the emergency departments are not the only cause of delays in treating patients.
Comment from the Editor
Andrew James is a ST8 Northern Ireland trainee soon to be on a revision arthroplasty fellowship.
We have published this article from Andrew to spark a more wide ranging discussion on the problems of staffing departments. There is an ongoing problem of
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JTO Features
BOA Ambassador to the 34th Hong Kong Orthopaedic Association Annual Congress 15-16 Nov 2014 Jeremy Granville-Chapman
700 delegates attended the 34th Annual Congress of the Hong Kong Orthopaedic Association which took place over the weekend 15th-16th November 2014 at the Hong Kong Convention Centre, a striking architectural structure that affords wonderful views of Victoria Harbour.
Jeremy Granville-Chapman
The Opening Ceremony’s guest lecture was delivered by Professor CY Leung, President of the Hong Kong Health Authority Board. His ‘State of the Union’ address provided a fascinating insight into Hong Kong’s public healthcare system. The population of 7.2 million (1 million over 65 years of age) is served by 67,000 employees in 42 hospitals with a budget of 6.4 billion USD (17% Government expenditure). Like many state healthcare systems, there is heavy demand for elective surgical services: median new outpatient waiting time is 55 weeks and the 90th centile lies at 128 weeks. The surgical wait is also longer than a year. There are 436 qualified Orthopaedic Surgeons, of whom approximately 100 work in private practice (one state sector Orthopaedic Surgeon per 21,000 population). Of course, there are many drivers of long waiting times, but standout points for me were the new to follow-up ratio of one to five
in outpatient clinics and the proportion of in-patient versus day-case surgeries. The theme for this year’s Congress was: “Sports Medicine: Inside, Outside and Beyond the Scope”. A diverse programme of papers, invited lectures, plenary sessions and symposia covered most areas within the Sports remit, whilst also offering something for those interested in the other domains of Orthopaedic practice. Two plenary sessions were particularly interesting. The first dealt with the painful degenerate unstable knee in the middle-aged athlete. Dr WL Chan gave a very clear synopsis of the current evidence concerning viscosupplementation in the knee. It was interesting to see that recent AAOS and NICE guidance does not recommend their use, and how, despite this, many of the audience felt that it remains a useful tool for selected patients in
their practice. Professor Andrew Carr then tackled the subject of placebo controlled trials in surgery. Amongst others, the classic Moseley (NEJM 2002) trial assessing arthroscopy in the degenerate knee was used to structure an argument for the use of placebo controlled trials in Orthopaedics. He presented his recent survey of members of the British Shoulder and Elbow Society’s attitudes towards placebo surgery. I was surprised how open surgeons are to the use of placebo in controlled trials, but of course, the issue of deception and the ethics of placebo use in routine practice remain controversial. There were excellent presentations by local and Japanese experts in osteotomy and ligament reconstruction and they offered algorithms for the management of this difficult cohort of patients – combined tibial osteotomy and ligament reconstruction seems, in their hands and selected patients, to provide good outcomes. As an aspiring Upper Limb Surgeon, the session addressing the painful and stiff shoulder was fascinating. The international faculty of Prof Carr, Dr Alessandro Castagna, Dr S-H Kim and Benjamin Ma offered a truly global perspective on the current philosophy, basic science and management of capsulitis, instability and cuff disease. Prof Carr began the session by presenting the Chingford
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framework. The hospitality was both formal and extremely welcoming and I thoroughly enjoyed the evening and the opportunity to meet Hong Kong surgeons and other visiting Ambassadors. The theme of sports surgery was well aligned to my interests and many of the sessions were therefore especially interesting. Overall, I was impressed by the global nature of the presentersâ&#x20AC;&#x2122; outlook: decision making, interpretation of evidence and orthopaedic practice seems grounded on the same principles in Hong Kong as it is in the UK. This similarity of approach will allow me to interpret with more confidence work produced from the Far East.
A view of Hong Kong from the Conference Centre window
studyâ&#x20AC;&#x2122;s epidemiological findings of shoulder pathology. This highlighted the disconnect between pathology and pain in the shoulder, which makes patient and treatment selection challenging in cuff disease. He presented the UKUFF Trial data: a multicentre prospective pragmatic trial assessing outcome and cost efficacy of rotator cuff surgery in over 50 year olds with degenerate cuff tears. At 2 years, 85% reported their shoulder was much or slightly better than before surgery. At 2.5K per QALY, cuff repair is highly cost effective. Tears that healed did better than those that did not. Re-tear rates were 40% with no difference between techniques. Interestingly, small and medium sized tears were no less likely to re-tear than larger tears and age >65 did not alter healing rates. Dr Castagna followed this by presenting his algorithm for the treatment of the stiff and painful shoulder. Dr Kim from Korea focused on stiffness in cuff disease and described his approach towards management of the tight capsule; he releases the inferior capsule in 70% of his arthroscopic rotator cuff repairs,
something I have not seen done before. All speakers noted the need for further basic science input to address the biology challenge in rotator cuff surgery that they now feel represents the point of weakness in our armamentarium. The prize paper session covered both basic science and clinical research projects. The quality of the papers was excellent. I was impressed that trainees were producing prospective, comparative trials during their programme and the basic science studies were well conceived. The winning paper reported on an RCT comparing anatomic single bundle and double bundle ACL reconstruction: another paper demonstrating equally good results with both techniques. A lunchtime workshop focused on tendinopathy and the basic and clinical science of autologous tenocyte implantation. The basic science behind this technique seems encouraging and one year and 4.5 year results from Australia are encouraging for clinical benefit in recalcitrant cases. It will be interesting to see how
this technology matures and how it compares to PRP injection. The Saturday evening involved a sumptuous banquet given in the waterfront restaurant. Traditional Chinese crafts were beautifully demonstrated before dinner and we were treated to a superb soccer skills demonstration. The guest speaker of honour gave an interesting insight into paralympic sport and its medical support
Jeremy speaking at the Congress
I would like to thank both the BOA and the Hong Kong Orthopaedic Association for affording me the honour and the opportunity to attend the 2014 HKOA Congress as the BOA Young Ambassador. Jeremy Granville-Chapman is an ST8 trainee in the Defence Deanery. He is currently undertaking an Upper Limb Fellowship at Wrightington. A post- CCT trauma fellowship will complete his training.
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JTO Features
Setting Priorities for Research in Orthopaedics within the UK: The James Lind Alliance Prof Andrew Price
The drive to develop evidence based Orthopaedic Surgical practice requires assessment of established and newly developed surgical procedures, together with non-operative treatment strategies. Owing to competition to attract research funding, it has become increasingly important to prioritise key areas of orthopaedic research.
Andrew Price
Stakeholders in this process of research topic prioritisation, include patients, the public, carers and researchers. For many years, researchers have set the agenda, with little or no space for the voice of the patient or the public in this process.
of research questions with uncertainties that patients/carers/ clinicians all agree on. This process has been supported by the National Institute for Healthcare Research (NIHR), who have adopted JLA methodology as the gold standard.
The James Lind Alliance (JLA) (www.lindalliance.org) is a non-profit making organisation, founded in 2004 and specifically created to address this problem by bringing patients, carers and clinicians together. By stakeholder consensus, they determine what research topics should be prioritised. This system offers better alignment
The JLA has developed robust qualitative methodology to perform the process of priority setting. Following the creation of a JLA PSP Steering Group, uncertainties are identified and collected through on-line surveys and face-to-face workshops. The data is analysed and sorted bringing forward a long-list of research questions, to a workshop
where consensus prioritisation occurs. The final output of the process is a ‘Top Ten’ list of the questions to be addressed in the given research area. The ‘Top Ten’ list of uncertainties is then published on the NHS Duets web-space and disseminated to all stake holder organisations (www.library.nhs.uk/duets). Over 30 JLA PSPs have now been completed, each with its own top ten priority list. Between 2012 and 2013 the first Orthopaedic JLA Priority Setting Partnership was delivered in Oxford, focusing on developing research priorities for Hip and Knee Replacement surgery.
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The PSP successfully delivered a ‘Top Ten’ list of research uncertainties (Figure 1). There was immediate engagement with NIHR to promote the list as research questions across all their funding streams. The priorities were adopted by the British Association for Surgery of the Knee (BASK), the British Orthopaedic Association (BOA) and Arthritis Research UK (ARUK).
The BOA was an active collaborator in the Hip and Knee Joint Replacement PSP. As a result of that engagement and the success of the Hip and Knee Replacement PSP the BOA Research Committee undertook a commitment to developing a greater portfolio of JLA PSPs across orthopaedics. In partnership with the JLA Administrative Hub that has
been set up at the Oxford Biomedical Research Centre, the BOA Research Committee has undertaken to develop a series of PSPs across the spectrum of orthopaedic musculoskeletal disease. At present new PSPs exist investigating, ‘Shoulder Surgery’ and the ‘Surgical Treatment of Early Knee Osteoarthritis’. Further PSPs are planned for Orthopaedic Trauma,
The final Top Ten priorities 1
What are the most important patient and clinical outcomes in hip and knee replacement surgery, for people with OA, and what is the best way to measure them?
2
What is the optimal timing for hip and knee replacement surgery, in people with OA, for best post-operative outcomes?
3
In people with OA, what are the pre-operative predictors of post-operative success (and risk factors of poor outcomes)?
4
What (health service) pre-operative, intra-operative, and post-operative factors can be modified to influence outcome following hip and knee replacement?
5
What is the best pain control regime pre-operatively, peri-operatively and immediately post-operatively for hip and knee joint replacement surgery for people with OA?
6
What are the best techniques to control longer-term chronic pain and improve long term function following hip and knee replacement?
7
What are the long-term outcomes of non-surgical treatments compared with operative treatment for patients with advanced knee/hip OA?
8
What is the most effective pre- and post-operative patient education support and advice for improving outcomes and satisfaction for people with OA following hip/ knee replacement?
9
What is an ideal post-operative follow up period and the best long term care model for people with OA who have had hip/knee replacement?
10
What is the best way to protect patients from the risk of thrombotic (blood clots, bleeding) events associated with hip/knee replacement?
Figure 1: James Lind Alliance Priority Setting Partnership for Hip and Knee Replacement Surgery
Hand Surgery and Revision Joint Replacement Surgery. In summary, the James Lind Alliance has developed a robust method for determining patient and public focused research priorities. This process has been adopted by the BOA, along with NIHR, ARUK and other funding bodies. The process will eventually drive more patient facing clinical research. Professor Andrew Price specialises in all types of Knee Surgery. He graduated from Cambridge University and completed his PhD at Oxford University. He is a Professor of Orthopaedic Surgery at the Nuffield Orthopaedic Centre, University of Oxford. He has developed three major themes of work in his research programme: • Investing the aetiology, progression and response to treatment of patients with early knee osteoarthritis; • Understanding outcome and improving decision making in hip and Knee joint replacement surgery; • Clinical RCT’s in Orthopaedics
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JTO Features
How does the National Joint Registry Support Research? J. Mark Wilkinson, NJR Research Subcommittee Chair Eve Riley, NJR Research Officer
The National Joint Registry for England, Wales, and Northern Ireland (NJR) is the world’s largest research-active joint replacement registry. As the NJR continues to mature in its second decade it has an ever increasing ability to provide data that helps researchers’ answer important questions that improve the lives of patients undergoing joint replacement. At the same time, the issue of security of person identifiable data (PID) continues to make media headlines. We have also witnessed substantial changes to the way our national bodies control access to PID. In this brief review of our recent and current activities we outline how the NJR has evolved to meet these dual responsibilities.
The NJR resource
J. Mark Wilkinson
Eve Riley
The NJR collects information about joint replacements of the shoulder, elbow, hip, knee, and ankle performed on patients in England, Wales and Northern Ireland. The NJR dataset holds over 1.8 million recorded joint replacement episodes. The NJR dataset can also be linked through the use of unique patient identifiers to other health and social care resources, such as Hospital Episode Statistics (HES), the Patient Episode Database for Wales (PEDW), national Patient Reported Outcome Measures (PROMs), and the Clinical Practice Research
Dataset (CPRD). The linked dataset is thus a uniquely powerful resource for research into the range of biological, mechanical, clinical, economic, and social factors influencing the outcome of joint replacement, and to establish the impact of joint replacement surgery on the well-being of the population. Access to NHS datasets, including HES and PROMs, is managed for DoH by the Health and Social Care Information Centre (HSCIC). Since publication of a review by Sir Nick Partridge1 in June 2014 the HSCIC has set in place new guidance and procedures2 for access to and use of these datasets. They also place clear responsibility on the part of the NJR and other partners to use of the data only for the specific purpose for which the data was shared.
How is research using the NJR resource managed? The Research Subcommittee (RSC) is responsible for delivering the research agenda of the NJR. The RSC’s aims are to maximise data access for researchers and to promote the profile and branding of NJR outputs, but also to protect the NJR dataset and strengthen its governance through safe, effective, and efficient data management in line with UK legislation. We have recently reviewed and revised our research strategy. We aim to help research applicants successfully navigate
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the ‘legislative waters’, and generate high-impact research outcomes for both patients and the profession. These developments include a new single entry point for all research applications arising within or external to the NJR, the development of an annually updated build of the research dataset, and plans to develop a bespoke data access portal for researchers. We have also reviewed our processes for the management of approved projects.
The NJR research pathway The first step when submitting an application is to check that your topic of interest is not already being studied by checking the NJR research library3. If you are unsure, then a quick call to the NJR Research Officer will help clarify this. The next step is to download and complete a simple Expression of Interest (EOI)4 form that lets us know the area of research you are proposing. The EOI is then reviewed within the RSC to determine the complexity and feasibility of the proposed project. Applications requesting unlinked and fully anonymised NJR data are directed down the ‘external’ route, whilst applications requesting access to linked datasets or PID are directed down the ‘internal’ or ‘collaborative’ project route. Internal projects require participation of an NJR Steering Committee member co-applicant to guarantee UK data governance requirements for traceable PID.
What areas of research does the NJR support and how do we share the data? In 2014 we conducted a mapping exercise to better understand the current research environment and the key stakeholders in musculoskeletal research. Funding bodies have a responsibility to distribute a fixed budget resource for maximum impact within a given timeframe, and thus may set ‘priority’ topics to which applications must be aligned. The NJR also has a responsibility to share data that maximises clinical impact to provide an effective return to stakeholders. Our priority is to ensure that the research question posed justifies access to the data, and to minimise duplication and redundancy in the supported research. Proposed research must be of potential benefit to patients, feasible, relevant, novel, and ethically sound. Accordingly, we have established a broad set of themed areas within which we will consider applications for data access. Data must be shared within the prevailing legal framework in a way that is, where possible, cost-neutral to NJR. To address this need we are developing an online Research Data Access Portal to maximise safe access to, whilst retaining ownership of, the dataset. Once up and running access to the portal for approved projects will be made
using an access key unique to each project applicant. Work is also underway to develop a “research-ready” dataset, enabling researchers to utilise the NJR Annual Report dataset as a research resource. These resources will facilitate more comfortable engagement with the broader national and international research agenda, reducing the burden on researchers by providing a single, “clean” source of data; updated each year with a new cumulative dataset.
What research activity is currently going on? Work continues on the five-year extended NJR PROMs cohort. Analysis of the linked data started in summer 2014 and results will be included in an interim report shortly. Other work includes exploration of infection after hip and knee replacement, use of ‘mix and match’ components and research into joint replacement utilisation amongst different ethnic groups. You may be interested to bookmark a link to the NJR Research Library3, our home for all papers, publications, abstracts, progress reports and NJR updates.
Research Fellows The RSC also continues to foster its Research Fellowship scheme in partnership with the Royal College of Surgeons of England, designed to build registry-based research capacity within the
clinical orthopaedic community. Interviews for a new Research Fellow took place in February and a second recruitment round is planned for Autumn 2015. For advance notice of the next opportunity to apply make sure to sign up to the NJR e-bulletin5. Taken together, we hope that these changes to the design of the NJR research function will help to further unlock the potential of the register, building a strong foundation for future research activity. To get in touch with us or learn more about the programme of work underway, further details and guidance notes are available on the NJR website6. Mark Wilkinson is an arthroplasty surgeon with a special interest in the interactions between patients and their prostheses. He is also Chair of the NJR Research Subcommittee. Eve Riley is the NJR Research Officer - eve.riley@hqip.org.uk
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Features
Commissioning SOS: Can we use it to Save Our Service? Tim Wilton, BOA Vice President
The new commissioning environment is a minefield, and already has led to some very strange and often quite antagonistic systems being put in place. Both clinicians and commissioners may feel completely at sea about how to influence these issues. The BOA Executive are actively approaching Commissioners and the DH to influence the way that new contracts are introduced but a clear view has emerged on both sides that the input of local clinicians to local negotiations is vital to the generation of a good and integrated MSK service in their area.
It seems that the better and more patient-focused CCGs do all understand and embrace this concept of clinician involvement, and indeed that the clinicians involved must include those in the relevant specialities in local secondary care.
Tim Wilton
It is therefore essential that all consultants involved in such ventures are aware of the guidance that exists and can be supported by the literature and by your professional organisation. The BOA has already developed such guidance for Hip and Knee Arthritis, Hallux problems, Carpal Tunnel issues, Low Back Pain and the painful Shoulder. All of these documents are available on the BOA Website and they link to dashboards showing your local performance indicators concerning that particular clinical problem. More guidance documents will be developed shortly, but these existing ones cover six high volume areas of orthopaedics.
While many of us are concerned about the developing epidemic of â&#x20AC;&#x2DC;Dashboarditisâ&#x20AC;&#x2122;, the information contained in these dashboards is often interesting, frequently unknown to the clinicians in that area, and still more frequently prone to misinterpretation by non-clinical and non-orthopaedic individuals in the commissioning services.
The data for many large centres of population may show a certain level of operation for knee surgery, and many areas will be around the national average for most of these procedures. If your own NHS area has a skewed provision in that clinical problem for some reason then the commissioners may simply assume such variation is unreasonable and therefore decline to support it.
It is therefore vital that we all inspect our own, and also similar and surrounding hospitalsâ&#x20AC;&#x2122;, data in these online documents otherwise we may suddenly find that the commissioners have decided to cut by some huge margin the number of, e.g. Knee Replacements, they commission.
Figures 1 and 2 show the dashboard figures for TKR provision in South Derbyshire (with which I am fairly familiar!), compared to that for UKR in North Oxfordshire (which might be considered an outlier in some respects) in order to illustrate the difficulty.
How could this happen and how could they justify it?... you may ask! Well, somewhat surprisingly, in some circumstances the data can suggest that such action might be entirely reasonable!
It can be seen that across the board the provision of TKR in Derby seems fairly close to the national mean, and therefore the commissioners would hopefully perceive that provision to be
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reasonable and may not rock the boat. Of course they might still decide to suggest a reduced commissioning target, but at least it could not be on the basis that the figures showed unreasonable deviation from the national norm.
Figure 1: TKR dashboard for S. Derbyshire showing just below average TKR provision per 100,000 population. The volume can be seen to vary from rather high to well below average even during the 2 years shown! The 30 day readmission rate is average while 30 day re-operation rate is much lower than the norm. This demonstrates the importance of choosing the correct parameter to measure.
Figure 2: UNI dashboard for N. Oxfordshire. Note very high UNI rates at over 3 times the national norm, and 6 SD above mean. LOS and 7 day readmission are unremarkable. 30 day readmission seems rather high at twice normal but 30 day reoperation rate very low….again the clinical advisers would need to be AWARE!
In contrast, the N. Oxfordshire surgeons appear to perform something like three times as many Unicompartmental Knee Replacements as the national average. Now this may come as no great surprise to the practicing knee surgeon, who would not only expect that to be the case but might even be able to rehearse the arguments which lead to those surgeons performing in that way and how they justify the difference. More importantly, however, they would be able to point to the separate areas in the dashboard relating to High Tibial Osteotomy and to Total Knee Replacement. If those figures were inspected alone, one would once again find the N. Oxfordshire surgeons to be practicing as “outliers”, only on this occasion they are seen to be performing far fewer of both these procedures than the national norm (Figure 3 shows N. Oxfordshire TKR data). It can be seen that the charts are completed quarterly, and thus are ideally suited to demonstrate recent trends. If your unit has a higher than average number of a certain procedure being performed it would obviously be useful to know whether it is increasing or decreasing, especially if you make some change to the care-pathway which is designed to influence the throughput.
Figure 3: N. Oxfordshire TKR dashboard. Note the substantially below average TKR rate per 100,000 population, in keeping with the tendency to offer UNI. Note also that despite (or because of?) slightly above average LOS the other ‘complication indicators’ show extremely low readmission/reoperation rates!
Clearly from the clinical point of view these three treatments are performed for parts of the spectrum of Knee Arthritis, and therefore it might be reasonable to
inspect the performance of these three procedures at once to see whether there was a significant over-treatment (or indeed undertreatment!) of OA knee occurring in N. Oxfordshire. If we assess the amalgamated figures we find that actually there is no apparent overtreatment occurring and the overall number of HTO, UKR and TKR in that area appears within the normal parameters. There is clearly a gross distortion of WHICH operations are being performed, but if that is justified to the commissioners and they accept the arguments they may be perfectly happy with the commissioning even though the individual procedures seem to indicate gross variation from ‘normal’ practice. Indeed the Guidance documents themselves explain to the reader that the presence of variation is not in itself reprehensible, but simply a marker that some explanation should be sought before agreeing to the commissioning. In this particular case, the commissioners might even feel, once they are satisfied with the argument that large numbers of Unicompartmental Replacements could be in the patients’ best interests, that they might be delighted to have such a contract because they might find they could pay less per case than they would for full TKRs and yet have apparent clinical justification for their decision! That would depend upon the current tariff for TKR and UKR of course! The guidance documents may show quite the opposite of course: The possibility exists for the number of TKR to seem entirely reasonable and fair against the national norm, but if that hospital or area also does well above average numbers of UNIs and HTO there would be a potential overtreatment of OA against the norm. If this is occurring at a hospital you work in, or perhaps in >>
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JTO Features
an adjacent hospital, it is important to be aware of the fact as it could clearly impact on your own practice and without that background knowledge your department’s capacity for a meaningful discussion with the Commissioners will be significantly undermined. Referred to as “Quality Dashboards” it will be clear that the bulk of the information in fact relates to quantity rather than quality assessments. There are various surrogate indicators of quality of care and treatment, but they need to be interpreted with some caution. It is nevertheless useful to know whether you are discharging your patients faster or slower than those around you, but is much more meaningful when you can see (as the dashboard allows) that you have either a much higher or a much lower 7 or 30 day readmission rate for that condition. It is clear that some procedures are more adequately funded by the tariff and some are much less so. For that reason a part of the preparation for commissioning must be to assess your own unit’s variance against the norm for the full spectrum of procedures. Many hospitals pay great attention to this and employ many individuals in the accounts and business departments to assess and/or modify their position in these regards. However, some Trusts take the view that with each annual change in tariff, they make gains here and losses there, which in a normal DGH may largely cancel each other out. The ability of managers within the secondary care unit to influence the case mix is distinctly limited, and significant expenditure by the hospital on such monitoring may therefore be quite misplaced as they may have to treat the patients anyhow. In contrast, if the commissioners are willing to
flex their commissioning muscle, they may have more of an impact on the distribution of patients and this is crucially important to everyone in the secondary care unit as commissioners could possibly commission your unit selectively to do more of the procedures on which you are more likely to lose money. The case mix problems created by this sort of issue have been highlighted by the recent debacle in the Bedford/Huntingdon area. The take-over by Circle of contracts for T&O in the Bedford area coincided with their provision of the secondary care contract through the Huntingdon Hospital. The transfer of large numbers of simple cases away from Bedford not only undermined the finances of the hospital due to removal of workload, but also caused significant modification of the casemix of the hospital further impacting their financial viability. Of course, one would not wish to run through the whole gamut of local dashboards in each of the hundreds of units to gain a comparison. Happily the Commissioning guidance contains other useful ways of inspecting the data. The figures in the Procedures Explorer Tool tab gives a snapshot view of where different units stand as regards their volume of each procedure. This can be displayed according to the CCG, the Local Area Team, or the secondary care unit, and can therefore be used to un-pick some of the variances. Variance against the national norm is of course interesting and important. However, it is crucial to know that variation exists in the local case-mix, local referral criteria, and of course in the level of expertise available for certain treatments. If the Procedures Explorer Tool is used to its full
Figure 4: TKR Funnel plot for TKR provision by CCG. Bubble size reflects the activity in individual CCGs. Note the same plot can be made by GP Practice, Local area team, and by NHS region. Similarly the data can be presented for adults/paeds (where appropriate) and for arthroscopy, osteotomy, UNI etc, as well as for various sections of the many other pathways indicated. Interactive charts allow each Bubble to be identified on-line.
extent, one can sometimes demonstrate that the area in which you work has high, or low, rates for a given procedure whichever unit they are sent to. This implicates the referral system or thresholds rather than the secondary care unit processes. In contrast, adjacent units may have very different levels of a given treatment and it would have to be for them to give a clinical justification for those differences. Figure 4 shows the funnel plots for the provision of TKR in different places by area team, CCG and by secondary care unit. It can be seen that considerable variation exists between the places at all levels of assessment and we should all be looking at these differences for our local area and units if we are going to have a useful dialogue with the commissioners. These figures are available for many aspects of the surgery involved with the conditions of each dashboard, and there are similarly histograms for volumes of work delivered by each unit, and by area teams to facilitate easy comparisons. The wily consultant adviser will therefore have familiarised themselves with these prior to commissioning discussions!
There is a wealth of information available to all of us on the BOA/RCS websites through the Commissioning Guidance documentation. This is readily available to all of us, but we have to bear in mind that there are many other similar sources available to the commissioners themselves, the public and to our political masters. If we don’t familiarise ourselves with these guidance documents, we can perhaps not be too surprised if the commissioners make decisions based either on their interpretation of these same documents, or perhaps even formulate their opinions based on completely other information available to them! Tim Wilton has been a consultant arthroplasty surgeon at Royal Derby Hospital for 25 years, and maintains an active revision practice. He was on the BASK Exec for most of the last 15 years, and on the BOA Council for 5 of those years. Previously a Clinical Director and RCS regional adviser, he would like to emphasise the value that information can give to those negotiating with Commissioners and Trusts.
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JTO Features
Two Years in Malawi and out of Training Ashtin Doorgakant
In January 2012, I came back from Malawi in search of my first middle grade job in orthopaedics in the UK. I had been out of the system for two years, having taken the plunge with VSO.
My experience I spent my first year in a district hospital, Ntcheu, with only remote support at hand. This equipped me with an array of managerial skills. My clinical work on the wards involved working on very simple systems that seemed to make the biggest difference. One of my projects was about developing a de-rotation splint for use in lower limb traction. My final design was eventually published in the international journal Tropical Doctor. My operating opportunities were limited and I was careful not to overstep my own abilities. That said, I learnt many new skills and was doing amputations, skin grafts, osteomyelitis management and tension band wirings towards the end of that first year. I owe a lot of this to the dedication of visiting consultants, such as Steve Mannion from World Orthopaedic Concern (WOC).
Ashtin Doorgakant
For my second year, I joined the teaching hospital, Queen Elizabeth Central Hospital in Blantyre, where I operated under the direct supervision of Professor
Makandawire and Dr Jes Bates. I also met surgeons from other hospitals and from other parts the world, with whom I forged strong links and learnt a great deal. My surgical experience included a wide range of spinal surgery for TB, tumour and trauma. In terms of general trauma, I was able to participate in a number of major operations such as hemipelvectomies, knee and ankle fusions, pelvic reconstructions and IM nailings with the world-famous SIGN nail system1. I taught interns, medical students, clinical officers and nurses, making me more self-assured.
Orthopaedic care at the district hospital Having worked both in the district and city central hospital settings, I became aware of the discrepancies in care provision around the country. The bulk of the healthcare nationally is delivered by orthopaedic clinical officers, who have undergone a focused period of 3-4 years’
training to become specialised paramedics. There are very few orthopaedic doctors to supervise them in the district. I therefore undertook to provide them with a set of clear protocols written from a central Malawian hospital point of view. The book, published in September 2013 and entitled “Orthopaedic care at the district hospital”, is an example of international collaboration. It took just over two years to complete and was conceived with Malawi in mind, but is applicable worldwide. The book has been published within the Creative Commons license and is available for download as a PDF from its own website www.orthopaedic-care.co.uk.
How to organise your placement To embark on an orthopaedic attachment in a low resource setting requires planning and preparation. The right of the trainee to do that is enshrined in Lord Crisp’s report (Global Health Partnerships)2. Your programme director will often ask to see the logbook from a trainee who has been where you are going. One can go as time out of programme for clinical experience (OOPE), time out for research (OPPR) or time out for career break (OOPC). One can certainly go in between stages too, as I did. The myth of “career suicide” is often overplayed. One can go as an SHO or a registrar. The focus for the former will be to ensure that one keeps accumulating the golden stars for the portfolio as detailed
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BOTA/WOC guidelines for undertaking charitable surgical work in low-income countries I often reflect that I gained more than I left behind in Malawi. Whether all the work done by the host of volunteering medics abroad, many very junior, actually benefits the country is doubtful.
Ashtin applying straight leg traction in Ntcheu
in the person specifications of ST3 job adverts. For the latter, it is maintaining an up-to-date logbook and providing evidence of supervision as per ISCP. Even if taking time out of experience (OOPE), one is advised to keep some record of what one has achieved while abroad. WBA collection abroad can be difficult. However one has to persevere and most supervisors will recognise the importance of doing this. I would advise carrying paper versions of PBAs, CBDs, CEXs, in the likelihood of poor internet access. My personal portfolio consisted of a logbook of over 500 cases (for 2 year), 4 audit projects, 2 publications in peerreviewed journals, numerous courses, national and regional presentations as well as a keen involvement in teaching.
The culture and socio-economic realities of the local hospital force a change in the travelling medic’s attitude. Once I started seeing things from the point of view of the local doctors and staff and patients, I realised that, if I didn’t adapt to the environment, no matter how grand my ideals, they were bound to fail. My international mentors later echoed these feelings. This is precisely what has prompted me to draft BOTA/WOC charter for the traveling surgeon as well as guidelines to optimise their placement. These guidelines have been endorsed by both the British Orthopaedic Trainees Association and WOC and are downloadable from their websites. The BMA have very useful advice on their website to help plan time out, and run a very worthwhile course called “Broadening your horizons”. The Royal College of Surgeons in London has hosted a gathering of major stakeholders in the field of humanitarian orthopaedic and surgical work at a meeting called “Global Surgical Frontiers”. There are numerous organisations offering grants, bursaries and fellowships to trainees. I will finish by strongly recommending anyone with an
Ashtin and two nurses outside Queen Elizabeth Central Hospital
interest in global and developing world orthopaedics to sign up as members of WOC (UK). Working abroad has been incredibly fun for me. All the challenges faced were simply outdone by the brilliant rewards. If the bug is in you to go out and create your own experience, I’d say to you “Do it”! But plan it well too, so both you and your target destination get the most out of it. Good luck! Ashtin Doorgakant is ST5 in T&O, Mersey Deanery, WOC linkman for BOTA, Trainee Rep for WOC. He previously worked in Malawi in 2010-2011. He is Interested in Trauma Surgery, Foot and Ankle and Global Orthopaedics. He is co-editor of “Orthopaedic care at the district hospital”, Tyson Press 2013. Ashtin is married with two wonderful children and a very supportive (microbiologist) wife.
References 1. A free interlocking nail which doesn’t require Xray-guided insertion 2. http://www.dh.gov.uk/ prod_consum_dh/groups/dh_ digitalassets/@dh/@en/documents/ digitalasset/dh_065359.pdf (full report) http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/@ dh/@en/documents/digitalasset/ dh_066154.pdf (report summary)
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JTO Features
Orthopaedic Trauma Surgeons in the UK delivering world-leading clinical research – that’s a joke! Prof Matt Costa Contributing Author: Prof Amar Rangan
Five years ago we heard this sort of comment quite a lot. Not least from other sub-specialties in Orthopaedic Surgery. While there were undoubted pockets of excellence, there was no trauma research network, little methodological expertise and no track-record in either funding or delivery of large-scale clinical research projects. How far we have come.
Matt Costa
The UK orthopaedic trauma trials network currently holds over £10million in National Institute for Health Research grants alone, including six multi-centres NIHR Health Technology Assessment trials. The network has delivered complex research projects on time and within budget; in the last 12 months the DRAFFT (distal radius fracture) HeFT (heel fracture) and ProFHER
(proximal humerus fracture) trials have been reported to acclaim and controversy, both nationally and internationally. DRAFFT1 demonstrated that, in contrast to the existing literature and the strong trend in clinical practice, that there was no advantage to volar locking plate fixation compared with K-wire fixation for patients with a dorsally displaced fracture of the distal radius. The K-wire surgery was quicker for patients and much cheaper, even including societal costs such as time off work.
HeFT2 added considerable weight to the evidence-base with regard to the treatment of displaced fractures of the heel; providing further evidence that the anatomic reduction and fixation of the posterior facet of the sub-talar joint does not affect functional outcomes in the first two years after the injury.
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Rick Buckley, legendary trauma surgeon and former President of the world-leading Canadian Orthopaedic Trauma Society, recently said that the OTS Research Network will soon become the best in the world. High praise indeed.
ProFHER3 will also change clinical practice in the UK and indeed around the world. This trial compared operative versus non-operative treatment for patients with a displaced fracture of the proximal humerus. The results showed no benefit to surgical intervention, and again non-operative treatment was considerably cheaper for the NHS and society.
The AIM4 trial compares close contact casting with internal fixation for patients over 60 years with a displaced ankle fracture. AIM will answer another longstanding question which has troubled patients and surgeons for many years – the results are due very shortly...
So, we now have a trackrecord of delivering the sort of research evidence that not only informs practice, but also changes policy.
Orthopaedic Trauma Society, recently said that the OTS Research Network will soon become the best in the world. High praise indeed.
This success is largely down to the network of Principal Investigators in Orthopaedic Trauma Trials – over 100 trauma surgeons in 50 hospitals are named investigators on major trials. Most of these surgeons are not academics, but ‘proper’, full-time orthopaedic surgeons who nonetheless have given up their time and put in considerable efforts to improve our knowledge in trauma and hence our treatment for patients.
So, “Orthopaedic Trauma Surgeons in the UK ARE delivering world-leading clinical research”, and that’s no joke!
The trauma trials network is embedded within the new Orthopaedic Trauma Society. The OTS has also forged excellent research collaborations with, amongst others: the Trauma Industry, University Biomedical Research Units, the Injuries and Emergencies Specialty Group of the NIHR Clinical Research Network, the Royal College of Surgeons Surgical Trials Initiative and our trauma national audit programmes, the National Hip Fracture Database and Trauma Audit and Research Network.
This year promises to be even more exciting. The trauma research network will expand even further. At least two more major NIHR multi-centre trials will open. Plus, and perhaps most excitingly, the investigator initiated, commercially funded trial in hip fracture (WHiTE3:HEMI) will become the first major UK trauma trial led by an orthopaedic trainee collaborative; the CORNET group in the North East. The project is a multi-centre randomised controlled trial comparing the Thompson’s and the Exeter stems in the treatment of fractures of the neck of femur. The primary outcome is the EQ-5D, which will be collected alongside the NHFD dataset. The aim is to publish results in late 2016. Rick Buckley, legendary trauma surgeon and former President of the world-leading Canadian
Matthew Costa is Professor of Trauma and Orthopaedic Surgery at the Warwick Clinical Trials Unit and Honorary Orthopaedic Trauma Surgeon at University Hospitals Coventry and Warwickshire NHS Trust. His research interest is in clinical and cost effectiveness of musculoskeletal interventions and he is Chief Investigator for a series of randomised trials and associated studies supported by grants from the National Institute of Health Research and Musculoskeletal Charities.
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Features - Trainee Section
How to Train a Surgeon Danny Ryan, Francesc Malagelada, Peter Smitham
Germany
The way we train to become Orthopaedic Surgeons is again under review: often at these times comparisons are made between other English speaking countries such as Australia, USA and Canada. The training structures of these programmes require surgeons to work 72-88 hours a week. Rarely are comparisons made with our European counterparts who are struggling with a 48-56 hour pattern. Following the recent Inaugural Federation of Orthopaedic Trainees of Europe (FORTE) summit we wanted to investigate how our training compares with neighbouring countries. This is particularly important given the European Directive 2005/36/EC established the mechanism for automatic mutual recognition of qualifications across all Member States, based on length of training and title.
Since 2005 the German training residency programmes for Orthopaedics and Trauma have merged. After six years at medical school, doctors enter a 72-month residency based at one hospital. The first two years are part of a “common trunk”, including six-month periods in both ITU and A&E. This is followed by four years “specialist training”, of which one year may include research, rehabilitation or nonoperative orthopaedics. During this period several skills in prevention, diagnostics and treatment must be achieved. Examples include 300 ultrasounds, 315 procedures (including 10 spine and pelvic cases as first assistant, 10 hip and knee arthroplasties), 220 conservative treatments and 25 medical opinions for insurance or civil court. Trauma management includes ORIF (10 cases each in spine, shoulder, hip, femur, knee, ankle and foot) and involvement in the management of ten polytraumas. After this period many sit the European Board Orthopaedics and Trauma (EBOT) examination before undertaking fellowship training in trauma, paediatric or specialty surgery.
France
Danny Ryan
Francesc Malagelada
Peter Smitham
Residency in France currently includes a five-year programme with ten internships of six months each including vascular surgery and paediatric orthopaedic surgery. This is conducted within the public hospital structure, although recently participation within the private hospital has occurred due to an increasing number of residents. The aim is to have 180 hours theoretical teaching over the five years (=36h/yr). The structure includes a very pyramidal organisational structure with the
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Prof Steve Cannon and Danny Ryan at the inaugural FORTE summit at EFORT HQ in Switzerland
potential for everyone to graduate as the national exam is not compulsory. The salary within the public sector is considered poor resulting in a drain into the private sector. Additionally, residents are expected to manage all trauma and take full liability doing so.
Spain In Spain, after five years at medical school and one-year foundation period, trainees undertake a national exam known as the Medico Imerno Residente (MIR). Trainees are ranked nationally and can choose where and what they want to specialise in on a first come basis. Trainees spend their entire training in one hospital only. The first year trainees rotate every two months around a broad based curriculum including A&E, ITU, and plastics. On-call commitments during this period still include being on-call for orthopaedics. After this, trainees spend four years rotating around the different sub-specialties of trauma and orthopaedics. There are yearly exams with an optional exam at the end.
Portugal In Portugal after six years at medical school and one year of practical experience, 30-40 trainees enter
a six-year residency in the public hospital. This includes nine months General Surgery, three months each of Vascular, Plastic, Neurosurgery and six months Paediatric Orthopaedic Surgery. Year five and six have some particularly relevant orthopaedic targets including non-supervised consultations; and increasing exposure of surgical procedures aiming to perform 40 operations as assistant and 40 as surgeon. Year six internship requires trainees to run independent outpatient clinics and increased involvement in surgical procedures either as assistant (30 procedures) or as a surgeon (70 procedures). The aim of the programme is to achieve 80% trauma and 20% elective surgery.
Finland Across Finland there are 69 orthopaedic residents in training in five university teaching hospitals. Training consists of a six-year program, including nine months as a general practitioner, two years and three months of general surgery, and three years of orthopaedic specialty training. Included in this are; 30 hours of mandatory training in leadership and administration, 80 hours of orthopaedic theory and 14 hours of radiography training. Examinations
are based on three major orthopaedic textbooks, knowledge of the last three years of the top five orthopaedic journals, and relevant medicolegal literature. Currently the EBOT exam is optional.
Malta Malta has two main hospitals and follows the UK system closely. There are 9 consultants and 11 specialist registrars in the region. Higher surgical training is for six years, three of which are based in Malta and then two years in either Oxford or London, before spending their final year in Malta. Trainees then undertake either the EBOT or FRCS examination. Wednesday teaching is linked with Oxford but there are additional teaching sessions on Saturday as well as research opportunities.
Summary As with all training schemes there is a strong reliance on gaining orthopaedic knowledge and learning specific key clinical skills that can be assessed in a formal exam. There appears to be some discrepancy in the actual surgical exposure, operative experience between systems and the varying independence of the surgeon once qualified.
Many of the other fundamental skills required to become a good surgeon are not formally assessed. These include: awareness of ones limits and to gain patient confidence along with accurate note keeping. A strong practise in clinical governance is fundamental in modern medical practice, critiquing the literature and undertaking new research. Many of these skills are tested through the additional appraisals and formative assessments within systems such as the ISCP. However, some skills are less tangible and although important are sometimes ignored. These include preparation in how to get the most out of a training programme, how to work well and lead a team, working in a flexible, efficient and safe manner. Maybe most importantly of all the skills of how to recognise and deal with failure, or how to prevent burnout are rarely covered. This is where a mentor is key. At this time there are a number of external influences acting on our training, and methods and goalposts are moving constantly. Reviewing the training programmes of our friends in Europe shows how much further developed our system is: however, the question remains, what sort of surgeons are we aiming to train for the future? Danny Ryan is the BOTA web developer and ST3 in Severn Deanery currently working in Cheltenham and Gloucester Francesc Malagelada is a Clinical Fellow working at the Whittington Hospital Peter Smitham is the BOTA President and Clinical Lecturer at UCL and an ST8 on the RNOH rotation
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JTO Medico-Legal Features
Personal injury claims for children suffering back and neck pain following minor to moderate road traffic accidents: a personal view Bruce Summers
Over the course of 25 years’ experience of providing medicolegal reports for personal injury claims, I have experienced varying trends of soft tissue injury following accidents of minor to moderate severity. At first it was simply neck pain following rear impact road traffic accidents (RTA’s), then back pain became increasingly prevalent. More recently complaints of wrist and shoulder pain and claims for post-traumatic stress and depression appear to be cropping up more regularly than before.
The concept of low velocity impacts causing injury, and the request by medico-legal firms for experts with an understanding of the mysterious “Delta V”* backed by convoluted equations relating to Newton’s second and third laws of motion, brought a moment of light relief to a quasi-orthopaedic specialty not known for its scientific exactness. However, of late, I have experienced a worrying trend of children aged 16 years or under appearing for medico-legal consultations for non-specific back and neck pain after RTA’s of minor or moderate severity. Bruce Summers
A detailed audit of my medicolegal instructions between 2005
and 2013 (Table 1) has indicated an increase in claims for such children from 1.4% of all total requests between 2005-2010, including non RTA claims, to 3.3% between 2011-13. These appear small percentages, but in real numbers this equates to seeing nearly 5 per year from 2005-2010 to nearly 10 per year from 20112013. In the year 2014, which is not included in the audit, this increase has been sustained. There has been no change in my practice or association with solicitors or medico-legal firms which might have occasioned such a trend, and the number of total claims I have dealt with has dropped by 10% between these
two periods of time. The figures comparing the two time periods does not indicate any change in symptom recovery and the delay from accident to report (not to settlement) has shown a slight fall but remains long at 16.8 months in the last three years. Of course I accept that my findings may not represent what is happening more generally with other medico-legal experts, and statistically there may be many other explanations for the apparent increase, but I do worry that this may be a damaging trend and that claims are being submitted on behalf of children by their parents or litigation friends without fully appreciating the possible negative consequences of the medico-legal process. Clearly children suffering injury are entitled to compensation under the law as much as adults, but I know that for some of my adult patients, their symptoms are difficult to explain and difficult to refute, and I am often left with a feeling that my opinion and prognosis is as imagined as their injuries. Faced with a child too young to even remember the accident, and with many side-long glances to a parent urging recall on their floundering offspring, these feelings are doubled. Many of the very young children take no
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part at all, except as bemused and disinterested bystanders, with the entire history being given by the parent or guardian, and the examination can feel very uncomfortable at times being little more than an unnecessary physical intrusion on a normal child. Like many of my colleagues, I worry that the medico-legal process, for which I appreciate I am fully part of, can be damaging to those who may be psychosocially vulnerable. With adults I can accept that they are engaging willingly in this process but with children it is different, they are largely passive hostages to usually a very modest financial fortune, for which in return they undergo a lengthy litigation process, including required appearances in front of a judge to ensure a fair outcome. That of course is only very reasonable in the situation of serious physical or psychological injury but one wonders if it is really necessary for a child with minor spinal pain largely forgotten. Many of the children I have seen are clearly quite resilient and will sit in bemused boredom during the medical examination, but
Year
some, and certainly those seen more recently, have clear and severe psychological disturbance almost certainly unrelated to the minor accident, but in whom the injury is depicted as the instigator of their symptoms. In these children the process is harming, deflecting and delaying the child away from appropriate management. Even in those without psychological issues, a lengthy litigation process fosters an attitude which dwells on pain and disability, and obstructs the normal process of healing. I do not believe that parents and guardians, are knowingly using children as a source of financial gain but I feel that they can get caught up in the unrelenting slow and rolling process of litigation without fully appreciating the hidden dangers. I am not certain how this matter could be addressed, or indeed if this is a concern shared by my colleagues. Clearly it is incumbent on solicitors, medico-legal agencies and all involved in the legal process to warn the families and litigation friends of prospective young claimants of the risks involved. Perhaps very early settlement with small sums with
minimal medical intervention, or fast tracking children through specific experts such as Paediatricians, or the shortening of limitation time to prevent claims being initiated many years after the incident, might make a difference, but all these possibilities have their pitfalls. For my own part at the end of a report I simply stress the importance of urgency to avoid the possibility of harm to a child that can come from such a litigation process. But it doesn’t seem enough. *Delta V, in this scenario and put very simply, it is the change in velocity of a vehicle at the time of a collision.
Comment from Ian Nelson Serious spine injuries following road accidents are fortunately uncommon in paediatric spine practice, even in major trauma centres. The vulnerability of immature cervical spine structures makes this surprising. Injury prevention through child car seat design may contribute.
Number of patients (Male/ female)
Age at RTA In years
Age at report In years
Delay from RTA to report (months)
Full Recovery/ Minimal symptoms
Moderate Persistent pain
Severe pain and/ or severe psych. symptoms
Percentage of children in relation to total number of instructions
2005 - 2013
57 (24/33)
11.4 (3-15)
13.0 (7-21)
18.7 (2-84)
37 (65%)
13 (23%)
7 (12%) (3 with severe psych. symptoms)
2.6%
2005 - 2010
28 (12/16)
11.6 (3-15)
13.4 (8-21)
20.7 (5-39)
18 (64%)
7 (25%)
3 (11%) (1 with severe psych. symptoms)
1.4%
2011 - 2013
29 (12/17)
11.2 (7-15)
12.7 (7-19)
16.8 (2-84)
19 (66%)
6 (21%)
4 (14%) (2 with severe psych. symptoms)
3.3%
Table 1: Details of medico-legal claims for children aged 16 or less at time of road traffic accidents of minor to moderate severity and resulting in non-specific spinal symptoms.
Boyd (2002)1 reported 47% of 105 children involved in road traffic accidents experienced neck pain in an emergency department setting in Australia. A UK study suggested an incidence of 29.5%. The prognosis was favourable. None of the patients reported residual pain after 62 days on direct questioning. Children seem relatively immune to the chronic disability some adults report. It may be that Mr Summers’ paediatric claimants are finally catching up with the perceived rights of their parents! It has been reported that legislative change, with removal of compensation for ‘pain and suffering’ (Cameron 2008)2 is associated with an ‘improved health status’ in the adult populations with neck injuries after road accidents. The UK Government seems determined reduce the costs associated ‘soft tissue injuries’ and it will be interesting to see if the observed trend is reversed with recent and future changes introduced by Ministry of Justice. Bruce Summers is a Consultant Orthopaedic and Spinal Surgeon at the Princess Royal Hospital in Telford, Shropshire and a Senior Tutor and Lecturer at the University of Keele Medical School. He has been involved in Medico-Legal reporting for over 25 years. The author welcomes any views relating to this issue and can be emailed to brucesummerslegal@ gmail.com or to the MedicoLegal Editor of JTO).
References 1. Boyd R, Emerg Med J (2002) 19:311-3 2. Cameron ID, Spine (2008) Feb 1;33(3):250-4.
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JTO Medico-Legal Features
Code of Practice for Orthopaedic Surgeons Preparing Reports in Personal Injury and other Cases (Part 2) Approved by the BOA’s Professional Practice Committee
The Medical Report The report should be provided along the lines given below: 1. Format and Style: The following general guidance applies to all reports a. Double spaced b. One side of the paper only c. Decent margins on both sides of the text d. Good quality A4 paper e. Bound in a manner that allows copying and filing f. Paginated with paragraphs numbered for ease of reference g. Clear, relevant section headings h. Should be comprehensible to a layman i.e. technical/medical terms should be explained i. There should be clear distinction between facts and opinions 2. Content and Layout: a. Title page should contain name, address, date of birth, employment status, accident/ incident date, interview/ examination date, date report was signed, details of instructing party/ies and their reference numbers, documents available to the expert
b. The general layout of the report may vary but should include: i. Index with contents page, reference to appendices if appropriate, expert’s abbreviated CV. In respect of the CV it is important that the expert provides a CV that specifically deals with why the expert is competent to deal with the case at hand rather than relying on a general CV. ii. Claimant’s history of the incident/injury and their account of subsequent investigations and treatment. Plans for future investigation/treatment iii. Review of all relevant medical records, X-Rays and scans iv. Outline of the claimant’s current condition and ongoing symptoms relating to the incident/injury including current medication v. The impact of the ongoing symptoms/disability on the claimant’s ability to work. In particular their ability to continue in their previous employment, was the time lost from work after the incident/injury justified, are they disadvantaged in the
open labour market and will they be able to work until their normal/chosen retirement age. Whether the claimant fulfils the definition of disabled under the Equality Act (2010), as this will impact upon the future calculation of loss of earnings. vi. The impact of the ongoing symptoms/disability on the claimant’s ability to cope in the home and in their recreational/ sporting activities. Is the situation likely to deteriorate in the future? Are there (or are there likely to be) care requirements? Do they now need help with certain tasks and chores in the home that they would not have required but for the injury? It is appropriate for the expert to identify those tasks and chores that the claimant will have difficulty with. However, these do not need to be quantified in detail as this is the province of the OT or Care expert. vii. Review of relevant past medical history and its importance with regard to injuries and ongoing disability viii. Detailed clinical examination
relevant to the injuries sustained ix. Discussion section, reviewing treatment and, if appropriate, considering further management. Whilst the report is for the Court, if it is glaringly obvious that further investigation/treatment is required which may clarify the reason for ongoing symptoms or potentially improve the claimant’s condition then, it is reasonable to say so. Are reports required from other experts e.g. Plastics, Psychiatry, Neurology etc.? x. A clear statement on causation. This may be apparent i.e. claimant hit by bus. However, it may not be at all clear i.e. claimant with history of back pain injures back at work or in RTA. Where it is not clear it is vital to point out that among experts of similar specialisation to yourself there would be a range of opinion on the matter and your opinion x because of a, b, c. On the question of causation, the expert will be required to provide an opinion on the balance of probabilities i.e. what is more likely than not.
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xi. A clear outline of the prognosis. Is the claimant able to continue working? Will they have to take premature retirement as a result of the injury? Will they need further surgery in the future? Are they going to suffer from arthritis in the future? Has a steady state been reached? Is a further report required in the future? Are there co-morbidities that would have prejudiced the claimant’s future prospects and quality of life in any case? It is important to remember with opinion on prognosis that the expert will be giving an opinion on future circumstances. As a matter of law, the Court will be concerned to understand the percentage chance of something occurring. xii. Throughout the report the expert should not stray from their own area of expertise. A useful rule is, “would I be comfortable giving opinion/ advice on this matter on the ward or outpatient clinic?” xiii. The report should contain the standard declaration and statement of truth that it is mandatory to append to all reports
Clarification of Issues in a Claim, including Part 35 Questions and preparation of Joint Statements with other experts 1. CPR 35 outlines the instruction and use of joint experts by the parties and the powers of the Court to order their use. If instructed as a single joint
expert, the expert should: a. Keep all instructing parties informed of any steps they may be taking, i.e. copy all correspondence to those instructing them. b. Maintain independence and impartiality, remembering their duty to the Court. c. If necessary, request directions from the Court. d. Serve the report simultaneously on all instructing parties. e. Not attend any meeting or conference which is not a joint one unless it is agreed by all parties in writing or the Court has directed that such a meeting be held and who is to pay the expert’s fees. 2. Where the value of the claim is likely to be in excess of a pre-determined level, or is a multi-track case, the Court may permit each party to instruct their own expert where it is proportionate to do so. The court has powers to direct discussion between experts and parties may also agree that discussions take place between their experts. In order to resolve the issues at any meeting of experts the instructing solicitor should provide multiple copies of all records disclosed in the action/ negotiation to the experts with a request that any points of difference be identified and countered upon in writing. 3. The purposes of the discussion between the experts should be to: a. Identify and discuss the issues in the proceedings b. Reach agreement on the issues
where possible and to narrow the issues in the case c. Identify the areas of agreement and disagreement and summarise the reasons for disagreement on any issues d. Identify action that may be taken, if any, to resolve the outstanding issues. 4. These arrangements for discussion should be proportionate to the value of the case. The majority of such meetings will take place by telephone or video link but, in multi-track cases, a face-toface meeting may be required. The parties, lawyers and experts should co-operate in drawing up an agenda although the primary responsibility lies with the instructing solicitor. The agenda should indicate areas of agreement and summarise these issues. It is helpful to have a series of questions to be put to the experts and, where possible, a joint agenda should be prepared. 5. If differences cannot be resolved in correspondence, experts should be encouraged to have a telephone discussion (a solicitor would not normally be present at a pre-trial conference). If the differences are still incapable of resolution experts should prepare, in light of the issues defined, a schedule of: a. Resolved issues and reasons for agreement b. Unresolved issues and reasons for disagreement c. A list of further issues that have arisen not listed in the original
agenda for discussion d. A record of further actions to be taken or recommended, as necessary, including a further discussion between experts. 6. Whether “hot tubbing” will replace or occur in association with preparation of joint statements remains to be seen at the time of drafting this update. 7. From a practical perspective the question often arises as to who should dictate/draft the Joint Statement, the expert for the Claimant or the expert for the Defence. There are no hard and fast rules on this. The important matters are: a. Jones v Kaney i.e. the expert should not significantly change their originally expressed opinion without clear and logical reasoning for that change b. Compliance with Court timetables after Jackson. 8. Under section 35.6 of the CPR either party may put written questions to the expert which must be “proportionate” and for clarification of the experts’ report. It is the responsibility of the party who initially instructed the expert to settle the fees for response to these questions.
Attendance at Conferences/Meetings with Solicitors, Barristers and Other Experts Experts may be asked to attend conferences with the legal team >>
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JTO Medico-Legal Features The vast majority of personal injury or medical negligence cases will settle and will not proceed to Court. However, the expert should always work on the basis that by accepting instructions, he/she is committing to attend Court to speak to their report.
that have instructed them together with other experts in complex, controversial or high value cases. The purpose of these meetings is usually to clarify important technical issues and improve the legal teams understanding of certain medical matters (although it is often surprising how well briefed/ informed some of the better Counsel and solicitors are in this area). These conferences may take place over the telephone, video link/Skype or in person. The expert should not attend these conferences without being thoroughly prepared, having read and re-familiarised him/herself with the case. Failure to do so will often lead to difficulties. The time spent considering the documents prior to the Conference should of course be added to the fee note for attending. The instructing party should already be aware of the likely fee range from the expert’s terms and conditions. The expert may be asked to attend in person. This can of course pose greater difficulties than telephone attendance, particularly for experts still in full time clinical practice. If it is mandatory for the expert to attend in person they should bear in mind that in addition to the issues discussed above it is very likely that Counsel wishes to see the whites of the experts eyes and put him on the spot to see how he is likely to stand up under cross examination in the witness box.
Attendance at Court The vast majority of personal injury or medical negligence cases will settle and will not proceed to Court. However, the expert should always work on the basis that by accepting instructions, he/she is committing to attend Court to speak to their report. Never work on the basis that the case is going to settle and therefore the report can be prepared without appropriate thought, care and skill. If the case proceeds to a hearing: 1. The solicitor should: a. Ascertain the availability of experts before a trial date is fixed. Experts should keep an up-to-date list of unavailable dates and the solicitor should not agree to a hearing on one of those dates. b. Notify the expert that the case has been set down for hearing. c. Keep the expert updated with timetables, i.e. dates the expert is expected to submit their report, the preparation of joint reports, if necessary, and dates and times when the expert is to attend court and the location of the court. d. Consider whether the expert may give evidence by video link. e. Inform the expert if the trial date is vacated. f. Arrange a meeting with counsel, the expert and other parties involved, where appropriate, prior to the hearing. g. Limit the time for court attendance to a half-day or the minimum time necessary for the expert to give evidence.
h. Ascertain the fees for all preparatory work and for attendance at Court and be in a position to pay that fee under the terms agreed. i. Inform the expert of the outcome of the case.
the timetable it must be accepted that this is the responsibility of the solicitor and the solicitor alone.
2. The expert has an obligation to attend court if called upon to do so. The expert should: a. Confer with counsel in advance of the hearing at a place to be agreed. b. Attend court, whether or not by subpoena c. Normally attend court without need for the service of a witness summons but, on occasion, the expert may be served to require attendance (CPR 34). The use of a witness summons does not affect the contractual or other obligations of the parties to pay experts’ fees. Unforeseen circumstances may mean that the expert has to attend to a patient or other matters and not the Court. Such circumstances should be rare and the onus must be upon the expert to justify their action. It should be noted that if an expert fails to attend trial, there will invariably be cost consequences on the party that he/she is providing expert evidence for. The experts’ evidence may be disallowed. Non-attendance by an expert without exceptionally good reason will invariably lead to the expert being sued.
The instructing party should notify the expert if and when the case has been settled and the outcome. They should also pay any outstanding fees promptly and give the expert instructions regarding the return or disposal of the medical records. It is not acceptable practice at the conclusion of a case for the expert to have to chase the agency, solicitor or insurer for payment as it should follow automatically.
It is the duty of the solicitor to forward immediately any court order to the expert. If a delay in forwarding a court order results in the expert’s inability to meet
The conclusion of the case
It is often useful/instructional for the expert to have feedback from the solicitor/insurer on the outcome, particularly if there were particularly controversial issue or significant disagreements between experts.
24th to 26th September 2015 Corn Exchange & Guildhall Cambridge England www.ishameeting2015.net
Thursday 24th September Hip Preservation Surgery (open and arthroscopic) with parallel Physiotherapy meeting Friday 25th September Diagnosis, Pre-hab, Rehab and Outcomes for Hip Preservation Surgery Friday night For the first time – a Gala dinner at Queen’s College Cambridge Saturday 26th September Advanced Surgical Techniques –Video and Interactive session Email: ishameeting2015@isha.net
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JTO Peer-Reviewed Articles
Metal Exposure after Hip Replacement and the Risks of Systemic Toxicity Prof. J. Mark Wilkinson
Large diameter metal on metal bearings in total hip arthroplasty and hip resurfacing (MOMHR) have been inserted in large numbers both in the United Kingdom and worldwide in recent years (Figure 1). However, because of high prosthesis failure rates the use of these devices has undergone a dramatic decline since its peak at 31% of cases reported to the NJR in 2007 to 1% of cases in 2013. More recently, dual modular necked femoral prostheses have also been implicated in early prosthesis failure1. Potential adverse systemic effects of metal release from failing prostheses remain a concern2, and our knowledge to date in this area is reviewed here together with the prospects for future understanding in this area3,4. Background
J. Mark Wilkinson
Cobalt and chromium are the principal metals released by MOM prostheses5. Both metals are essential trace elements in man, with physiological circulating concentrations of between 0.1 and 0.2Âľg/L. Blood levels of cobalt and chromium rise after MOMHR5,6, with late steady state median blood concentrations of between 1.5 and 2.3Âľg/L in patients with wellfunctioning prostheses7,8. The majority of MOMHR prostheses have been inserted in younger, more active patients, and the majority of these prostheses are functioning well. The median life-expectancy of prostheses in this age group equates to a duration of exposure to cobalt and chromium that is in excess of 20 years.
Can exposure to high circulating metal concentrations cause systemic illness? A failing MOMHR prosthesis is associated with circulating cobalt and chromium concentrations that may be several times higher than those seen in patients with well-functioning prostheses9. Case reports of patients with failed prostheses also suggest that very high blood metal concentrations are associated with systemic effects including cardiac, neurological, and endocrine dysfunction10-14. A recent systematic review of the relationship between metal exposure and features of systemic toxicity was conducted by Bradberry, Wilkinson, and Ferner15. In this review we searched Medline and Embase between 1980 and 28th
Figure 1: Plain pelvic radiograph showing a patient with a metal-onmetal hip resurfacing
February 2014 for published cases of possible cobalt or chromium toxicity associated with hip prostheses. Although there were 23 reports describing original case data, a total of only 18 individual patient cases were described within the reports. In 10 of these cases the patient had undergone revision of a fractured ceramic-containing bearing to a cobalt-chrome containing bearing and the source of the elevated systemic cobalt concentrations was ascribed to accelerated wear of the revision metalcontaining bearing due to ceramic 3rd body wear (Figure 2). The other eight patients had received a primary MOM prosthesis. Three main categories of systemic toxicity were identified, including neuro-ocular toxicity (14 patients), cardiotoxicity (11 patients), and thyrotoxicity (9 patients). The median blood cobalt concentration in these cases was 398Âľg/L (range 13.6 to 6521), and was substantially higher in the failed ceramic bearing group than in the primary MOM prosthesis group. Removal of the prosthesis in these cases was usually associated with a fall in systemic cobalt concentrations and an improvement in clinical symptoms.
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© 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 02, pages 42-43 Title: Metal Exposure after Hip Replacement and the Risks of Systemic Toxicity Author: J. Mark Wilkinson
Figure 2: Radiograph showing a fractured ceramic head after THA. The head and liner were subsequently exchanged to a cobalt-chrome on polyethylene bearing that later resulted in accelerated wear of the prosthetic head, metallosis, and grossly elevated whole blood cobalt concentrations.
How might we link systemic illness with metal exposure? Based on these findings we proposed toxicological criteria for assessing the likelihood that clinical features are related to cobalt toxicity15: clinical effects consistent with the known neurological, cardiac, or thyroid effects of cobalt, and for which any other explanation is less likely; increased blood cobalt concentrations (substantially higher than those in patients with well-functioning prostheses) several months after hip replacement; a fall in the blood cobalt concentration after treatment, accompanied by signs of improvement in features. When judged by these criteria, the systemic features in 10 of the reported cases were felt likely to be related to cobalt exposure from a metal-containing hip prosthesis.
Does chronic exposure to low metal concentrations cause systemic illness? The case for adverse systemic effects due to long term chronic low level elevation of metal concentrations associated with well-
functioning MOM prostheses remains unclear. Chronic industrial and accidental over-exposure to cobalt or chromium associates with solid organ damage including the heart, liver, kidneys, pituitary and thyroid glands, and thus there is a theoretical case for association after MOMHR. The United States Government Centers for Disease Control and Prevention regulations and advisories for cobalt recommends a threshold limit value of atmospheric cobalt of 0.02µg/m3 for exposed cobalt workers www.cdc.gov/niosh/topics/ cobalt. Biological monitoring for this level of exposure equates to a biological exposure index at the end of shift at the end of the work week of 1µg/L in blood and 15µg/L in urine. Linna et al16, found cobalt workers exposed to a blood cobalt level of 2.5µg/L over nine years had echocardiographic evidence of altered left ventricular function versus unexposed controls. These studies suggest that blood metal concentrations below the MHRA investigation threshold of 7μg/L have potential for association with adverse systemic effects. We undertook a detailed crosssectional health screen at a mean of eight years after surgery in 35 clinically asymptomatic patients who had previously received a MOM hip resurfacing (MOMHR) versus 35 individually age and sex matched asymptomatic patients who had received a conventional hip replacement (THA)17. All subjects underwent a detailed battery of investigations, including clinical history and examination, and assessments of cardiac, neurological, neuropsychological, endocrine, renal, hepatobiliary, and bone density and turnover. Cardiac ejection fraction was 7% lower (P=0.04) and left ventricular end-diastolic diameter was 6% larger (P=0.007) in the MOMHR versus the THA group. Total body bone mineral density was 5% higher (P=0.02) and bone turnover was 14% lower (P=0.006) in the MOMHR versus conventional THA group. Diuretic prescription was
associated with a 40% increase in the fractional excretion of chromium (mean difference 0.5%, P=0.03). In follow up studies in these patient groups we found that the MOM exposure patients had lower grey matter density in the occipital cortex and basal ganglia of the brain measured by MRI than the patients who received a conventional THA, but no other structural differences in the brain18. However, we found no evidence of clinical deficits in visual or auditory function in asymptomatic MOM patients versus the THA controls19.
Summary Exposure to very high circulating concentrations of cobalt associates with cardiac, neurological, and thyroid disease. We found in the majority of these cases the associating problem is accelerated wear of a cobalt-containing revision bearing used to replace a fractured ceramic bearing. The case for an adverse effect of chronic exposure to low circulating metal concentrations remains less clear. Our findings of differences in bone and cardiac function between patients groups suggest that chronic exposure to low elevated metal concentrations in patients with wellfunctioning MOMHR prostheses may have systemic effects. Longterm epidemiological studies that link registry data with other clinical datasets may provide sufficient power to definitively establish whether such associations are clinically relevant.
Clinical toxicological assessment of systemic features in patients with metal-containing hip prostheses Proposed assessment criteria for cobalt-related disease: 1. History: A MOM or a fractured ceramic-containing prosthesis
has been replaced by a metal component; local symptoms of pain are present; the patient’s symptoms are consistent with known cardiac, neurological, or thyroid effects of cobalt, and for which any other explanation is less likely. 2. Clinical and investigation findings: There are objective signs consistent with known cardiac, neurological, or thyroid effects of cobalt, for which any other explanation is less likely. Local abnormalities (damaged prosthesis, metallosis) on radiology or at surgery are present. 3. Timing: Clinical features develop months to years after factors increasing blood cobalt concentrations. 4. Cobalt concentration: Measured cobalt concentrations are substantially higher than those in patients with well-functioning prostheses. 5. Response to removal of the prosthesis: Blood cobalt concentration falls after removal of the prosthesis, and the fall is usually accompanied by clinical improvement. Mark Wilkinson is an arthroplasty surgeon with a special interest in the interactions between patients and their prostheses. His work includes studying the effects of metal exposure on bone, the heart, and other solid organs, and the risk factors for prosthesis failure.
Correspondence Email: j.m.wilkinson@sheffield.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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JTO Peer-Reviewed Articles
The rates of Thromboembolic events in patients undergoing elective hip and knee arthroplasty before and one year after the introduction of the NICE guidelines Dan Rolton, Oliver Pearce Contributing Authors - S Kantharuban, P Subramanian, M Joshi, S Shilston, L Taylor
In January 2010 the National Institute for Clinical Excellence (NICE) published new guidelines on the prevention of thromboembolic events for those undergoing elective hip and knee arthroplasty (Figure 1)1. One of the key areas from the new guidelines was that chemical prophylaxis should be continued after the patientâ&#x20AC;&#x2122;s admission period.
Dan Rolton
Oliver Pearce
The average time of clinical presentation for VTE in total hip replacement (THR) has been quoted from 17 to 27 days and in total knee replacement (TKR) as 7 to 16 days2,3. Providing ongoing chemoprophylaxis with low molecular weight heparin on discharge has presented a problem to orthopaedic teams as patients need to be able to self administer the therapy and require further monitoring in case of thrombocytopaenia4. The recent introduction of new oral anticoagulants such as dabigatran etexilate enables patients to continue prophylaxis in the community without the need for further monitoring.
Dabigatran etexilate is an oral thrombin inhibitor available in doses of 220mg and 150mg. The reduced dose is recommended for patients over the age of 75 and/or moderate renal impairment. Both doses of dabigatran have been found to be as effective as low molecular weight heparin (LMWH) in preventing thromboembolic events with a similar bleeding profile in patients undergoing hip and knee arthroplasty5. There has been concern that the change in guidelines which would enforce prolonged anticoagulation in the community
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Journal of Trauma and Orthopaedics: Volume 03, Issue 02, pages 44-47 Title: The rates of Thromboembolic events in patients undergoing elective hip and knee arthroplasty before and one year after the introduction of the NICE guidelines Authors: Dan Rolton, Oliver Pearce Contributing Authors: S Kantharuban, P Subramanian, M Joshi, S Shilston, L Taylor
with new therapies and limited monitoring would lead to high rates of bleeding related complications and may not reduce the rare symptomatic VTE. This retrospective cohort study aimed to compare a traditional VTE regime with the clinical outcomes of the NICE VTE protocol in patients undergoing elective hip and knee arthroplasty.
Methods Two groups of patients undergoing elective primary TKR and THR at Milton Keynes General Hospital were identified over a one year period. One group received a standard VTE regime common in many hospitals before the NICE guidelines. They received compression stockings and dalteparin chemoprophylaxis whilst an inpatient. On discharge
the dalteparin would be stopped and the stockings continued for a total of six weeks. The second group received a new protocol designed in response to the NICE guidelines by the orthopaedic department at Milton Keynes General Hospital. Patients were commenced on compression stockings and dalteparin (5000 units once daily commencing 1-12 hours after surgery) whilst admitted on the ward. On discharge they were changed from dalteparin to dabigatran (150mg once daily for 14 days in TKR and 28 days in THR) with compression stockings. The decision to keep patients on dalteparin in the immediate post-operative period was made based on concerns of wound problems with dabigatran directly after surgery6. Keeping to a single dose of 150mg for all patients simplified the prescribing regime for a new medication in the department where there was a high turnover of junior ward staff. Patients were excluded from the study if they were on other forms of anticoagulation preoperatively such as clopidogrel, warfarin or heparin for other medical conditions, undergoing revision arthroplasty procedures, had a contraindication to dabigatran, or died less than 60 days after surgery provided their death was not related to a thromboembolic event. For each arthroplasty procedure intravenous teicoplanin was given at induction and 12 hours post operatively. Total knee replacements had a re transfusion drain (Bellovac, Astra Tech Healthcare, Gloucestershire UK) which was removed at 12 hours.
Figure 1: NICE guidelines for VTE prevention in Hip and Knee Arthroplasty patients1
Evidence of a thromboembolic event such as a DVT or PE was identified from: the patient’s
electronic hospital record, Milton Keynes VTE database and reviewing the PACS radiology records for any positive diagnostic investigations for a deep vein thrombosis (DVT) or pulmonary embolism (PE). The surgery was performed by a group of seven consultants and two associate specialists in a district general hospital. The types of implants used for knees included: Cemented Scorpio knees (Stryker, Newbury, UK), Uncemented LCS knees (Depuy, Leeds, UK). For the hips: Cemented Exeter (Stryker), and Uncemented Trident-Accolade (Stryker) or Uncemented Furlong (JRI Ltd, Sheffield, UK). Statistical analyses were performed using the statistical software package IBM SPSS version 19 (SPSS Inc., Chicago, IL). The Mann – Whitney U test (nonparametric) was used to compare the incidence of VTE occurring pre and post NICE guidelines. Alpha level was set at p < 0.05.
Results In total 654 patients were included in the study. 322 patients on the traditional regime underwent a primary hip or knee arthroplasty of which 141 were THRs and 181 were TKRs. 332 patients on the new protocol were included of which 182 underwent TKR and 150 had a primary THR. The rate of thromboembolic events without prolonged anticoagulation was 4.3% (14 patients) in comparison to 1.2% p<0.01 (4 patients) after the prescription of dabigatran (Figure 2). Nine patients suffered a DVT and 5 >>
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JTO Peer-Reviewed Articles Extending the prophylaxis for VTEs beyond hospital discharge has been shown to reduce the rate of symptomatic PE and DVT in patients undergoing elective lower limb arthroplasty .
experienced a PE before the new guidelines. There were no PEs and only 4 DVTs in those on home dabigatran. Figure 3 demonstrates the distribution of thromboembolic events between THR and TKR before and after the NICE guidelines. Before the introduction of dabigatran there was an equal number of thromboembolic events in both THR and TKR groups however there were proportionally more DVTs in those undergoing a TKR (3.3% DVT vs 0.5% PE) in comparison with THR patients (2% DVT vs 2.8% PE). Patients on the new protocol saw proportionally
more DVTs in the THR than the TKR groups (2% vs 0.5%). No patients on the traditional regime required further surgery for haemarthrosis or bleeding problems affecting their arthroplasty. Four patients prescribed dabigatran required further surgery for bleeding related problems after their arthroplasty surgery. All of these occurred in cemented TKR patients following the introduction of the new protocol. However, none of these incidents occurred whilst the patients were on dabigatran
Figure 2: Rate of 60 day thromboembolic events on pre and post NICE VTE prophylaxis
Figure 3: Distribution of thromboembolic events at 60 days between THR and TKR before and after the introduction of the NICE guidelines
therapy. Two occurred within a week of surgery before dabigatran therapy was commenced and the other two occurred at day 23 and 64 post surgery, once therapy had stopped. One patient in each group was excluded due to death in the 60 days post-surgery but neither of these were related to a VTE.
Discussion Extending the prophylaxis for VTEs beyond hospital discharge has been shown to reduce the rate of symptomatic PE and DVT in patients undergoing elective lower limb arthroplasty 5,7,8. These findings are further supported by studies demonstrating that the majority of symptomatic VTEs present after hospital discharge2,3. Recent postal surveys of British orthopaedic surgeons have found varied approaches to VTE prophylaxis with a minority of patients receiving effective outpatient chemoprevention9,10. A guideline published by the American College of Chest Physicians in 2004 recommended extended prophylaxis in TKR up to day 10 post operatively and between 28 and 35 days in THR11. Despite these guidelines a study by Warwick et al. of nearly 15,000 hip and knee arthroplasty patients from a global registry found that over a third of THR patients did not receive the recommended duration of chemoprophylaxis12. The publication of the new NICE guidelines for VTE prophylaxis has formalised the need for ongoing chemoprophylaxis in hip and knee arthroplasty patients. Surgeons are presented with a choice of continuing subcutaneous low
molecular weight heparin or prescribing one of the new oral anticoagulants. Dabigatran is excreted predominately via the renal system and has a half-life of approximately 16 hours making it suitable for once daily oral administration without the need for self-administered subcutaneous injections and monitoring for thrombocytopaenia13. Using the 150mg dose of dabigatran offers a more cost effective means of providing on going chemoprophylaxis once the cost of administering low molecular weight heparin is taken into account14. Drugs such as dalteparin benefit from being used for many years and the effects in the perioperative period are well appreciated by orthopaedic surgeons. They have a half-life of approximately 3 to 4 hours so that any bleeding related complications in the immediate postoperative period secondary to anticoagulation can be addressed by immediately discontinuing the medication. The formulation of the Milton Keynes protocol allowed us to treat our patients within the new guidelines whilst continuing the same inpatient prophylaxis in the immediate post-operative period. The results of our study demonstrate that by applying our protocol in accordance with the new guidelines we have managed to significantly reduce our rate of symptomatic VTE from 4.3% to 1.2% (P<0.01) in the 60 days following surgery. Furthermore the rates of symptomatic PE reduced from 1.2% to 0%. To date there are no studies that have compared extended dabigatran in combination with LMWH anticoagulant therapy for prevention of VTE in hip and knee arthroplasty patients.
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Š 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 02, pages 44-47 Title: The rates of Thromboembolic events in patients undergoing elective hip and knee arthroplasty before and one year after the introduction of the NICE guidelines Authors: Dan Rolton, Oliver Pearce Contributing Authors: S Kantharuban, P Subramanian, M Joshi, S Shilston, L Taylor
Dabigatran has been subject to large multicentre randomised controlled trials in comparison with low molecular weight heparin for extended VTE prophylaxis in hip and knee arthroplasty. The RE-NOVATE and RE-MODEL trials compared a 40mg daily dose of enoxaparin with 220mg and 150mg doses of dabigatran in 2651 THR patients and 1541 TKR patients15,16. These studies demonstrated no significant difference in symptomatic or asymptomatic VTE rates between different doses of dabigatran and enoxaparin. The symptomatic rates of VTE in the 150mg dose group for THR and TKR were 0.9% and 0.5% respectively. The rates of symptomatic VTE using the Milton Keynes regime was 2.0% in the THR group and 0.5% in TKR patients. The difference in VTE rates between our study and the RE-NOVATE could be explained by the difference in study times. The RE-NOVATE defined a treatment period up to three days after the last dose of dabigatran which would take the total period to a maximum of 38 days post operatively in comparison with our study which looked at events up to 60 days. If symptomatic VTE rates were considered over the same period then the rate for the Milton Keynes regime would reduce to a comparable 0.7% in THR patients. Table 1 illustrates
RE-MODEL Symptomatic THR VTE rate Symptomatic TKR VTE rate
the rates of symptomatic VTE in patients on 150 mg dabigatran in the RE-MOBILISE, RE-MODEL, RE-NOVATE and the Milton Keynes regime. The RE-NOVATE and RE-MODEL trials found no significant difference in reoperation rates for bleeding between LMWH and dabigatran. All of the patients requiring reoperation in our study underwent cemented TKR. This represents 2.2% of TKRs on the new regime which is higher than the 0.1% seen in the RE-MODEL trial. This may reflect the shortened duration of treatment in these patients who received an average of 8 days therapy. Rates of infection in our study, including those treated by general practioners for superficial wound related problems, were similar before and after the change in guidelines. A smaller study by Gill et al. found higher rates of wound related problems in hip arthroplasty patients after the introduction of dabigatran compared with LMWH6. The dabigatran was commenced in the first 24 hours following surgery in comparison to the Milton Keynes patients who were started on dabigatran at discharge. None of the 654 patients in our study sustained a fatal VTE although two patients died from non VTE related causes. Hunt
RE-NOVATE
RE-MOBILISE Milton Keynes Protocol
0.9% 0.5%
2.0% 1.3%
Table 1: Rates of Symptomatic VTE in the RE-MODEL, RE-NOVATE, RE-MOBILISE trials in comparison with the Milton Keynes protocol
0.5%
et al. have demonstrated that the 90 and 45 day mortality from THR and TKR has reduced significantly between 2003 and 2011 which encompasses the introduction of the new NICE recommendations18,19. They also found that VTE prophylaxis was associated with a reduction in THR mortality but not in TKR deaths. The use of the single lower 150mg dose of dabigatran for all patients implies that those patients under the age of 75 with normal renal function receive sub therapeutic treatment. However, the multicentre studies mentioned previously demonstrate equally low VTE rates for both 220mg and 150mg doses. The use of the lower dose in this study proved both effective and safe in a large patient population. The results presented here are subject to limitations. Patients presenting with a VTE to an institution away from Milton Keynes may not have been included in the study if the event was not mentioned in their outpatient follow up. Patientsâ&#x20AC;&#x2122; clinic letters were looked at to identify these events and some patients were found to have had treatment for VTEs and PEs at other hospitals. As this study was retrospective we did not analyse wound related problems that were not subject to reoperation or treatment with antibiotics once discharged on dabigatran. The study assumes that all patients were fully compliant with their medication although this was not formally checked. VTE in post-operative arthroplasty patients is a multifactorial condition and the results from our 657 patients may not have significant power to draw definitive conclusions.
Conclusions The Milton Keynes VTE protocol formulated in response to the recent NICE guidelines has shown a significant reduction in symptomatic VTE in patients undergoing primary hip and knee arthroplasty. The regime combines the advantages of LMWH and oral thrombin inhibitors to provide effective and acceptable extended VTE prophylaxis in a district hospital setting. Larger prospective studies would be beneficial in fully evaluating this regime. Daniel Rolton is a ST8 Trauma and Orthopaedic registrar from the Oxford Deanery. Oliver Pearce is a consultant Hip and Knee Surgeon in Milton Keynes Foundation University NHS Trust. He is Director of Trauma Surgery, and lead clinician for Orthopaedic Research. He runs the department of Musculoskeletal Sciences at the newly formed University of Buckingham Medical School. He is also visiting Professor at the University of Bedfordshire (ISPAR).
Correspondence Email: danrolton@hotmail.com Email: oliver.pearce@mkhospital.nhs.uk
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
The Rise of Big Data and Can it be Used to Compare International Healthcare in Orthopaedic Surgery? Andrew Gordon
In this brief review article I endeavour to give clinicians an understanding of Outcomes Research and briefly describe how it may assist future resource planning. We now live in the era of Big Data, a description of datasets so large and complex that standard or typical analytical processes cannot cope with the interpretation or analysis. This data generation occurs across all industries, and is a resource that could be used to improve global healthcare.
Within the UK there are many examples where Big Data has been captured and is being used in an attempt to improve delivery of healthcare and clinical and patient-related outcomes.
Andrew Gordon
The BOA is leading the way with the Quality Outcomes Project1 and is assisting with eight emerging registries or audits. In addition, at a national level, the National Joint Registry (NJR), National Hip Fracture Database (NHFD) and the Trauma Audit and Research Network (TARN), contribute significantly. In the UK, the Health and Social Care Information Centre collects
details of all patient admissions, outpatient appointments and Accident and Emergency visits and records each period of care as an ‘episode’. These administrative Hospital Episode Statistics (HES) can be used by national regulators, healthcare providers and ‘service users’. Numerous other international general and specific datasets are also in existence, examples include; The Swedish, Norwegian and American Joint Replacement registries and the Australian Institute of Health and Welfare Statistics and The California Office of Statewide Health Planning and Development Database.
However, despite this abundance of data, significant challenges remain, including how we want this disparate data to work for us and how to meaningfully analyse, share, validate, and interpret it. For most clinicians, this new vista remains unexplored however increasing numbers of medical professionals are engaging in the domain of outcomes research. Most clinicians will be familiar with the concept of ‘levels’ of medical evidence and clinical trials; most will also be aware that there is a paucity of higher level trials in orthopaedic surgery. The current gold standard trial
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© 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 02, pages 48-50 Title: The Rise of Big Data and Can it be Used to Compare International Healthcare in Orthopaedic Surgery? Author: Andrew Gordon
remains a randomised clinical trial (RCT). The RCT is an excellent method to compare therapeutic variables but may not reflect a ‘standard’ hospital’s practice. The generalisability of RCT studies to physicians and hospitals not part of the original trials are well documented;2 and extrapolation of ‘outcomes’ is problematic. Outcomes research is a methodological technique that analyses all patients (usually from large specific databases) and reflects population heterogeneity. It also assesses the ‘provider’ and considers variables such as volume number, teaching status and subspecialisation. Dataset analysis involves large numbers of patients which permit powered subset confounder analysis, however it still requires hypotheses, inclusion and exclusion criteria, outcomes/ endpoints, comparison groups and covariates. It is not data mining but is a robust analytical process. This method of research therefore still analyses outcomes but the emphasis is at physician, hospital, national and international level. Publication of outcomes research using national datasets is increasing, and there are numerous examples of international orthopaedic publications from the Australian Orthopaedic Association NJR Registry3, The Danish National
Registry4, and the Norwegian and Swedish Arthroplasty registries. In the UK, the seminal paper by Smith et al reported the outcomes of metal on metal arthroplasty and its inherent issues5. To date, there are twenty five publications listed on the UK’s NJR website linked to research using the NJR data set. However, there remain challenges. It seems apparent following discussion at the recent British Hip Society AGM that currently the NJR may not be a valid tool to analyse data at individual surgeon level and there was much debate concerning the data for reporting outcomes at unit level. NJR aside, whatever ‘level’ of analysis the datasets are used for, questions about the validity of their use remains. For example, in a recent paper, Sabah et al conclude that the NJR underestimates the revision rate for metal on metal hip replacements6. Ongoing validation programmes to improve the data, hopefully negating these questions in the future, are in place for all clinical registries. An additional approach to outcomes research is to use administrative data. One criticism levelled at administrative datasets is that the data is not collected by clinicians but by coders with limited understanding of the complexities of medical care. However, there is
robust training for coding staff internationally and inaccuracies which may occur tend to be random and therefore unlikely to bias findings. Administrative databases are not meant to replace clinical data registries but they may complement each other. Chang et al have used the analogy of screening and diagnostic tests when analysing outcomes from administrative datasets and clinical databases7. Outcomes generated from analysis of administrative data which are sensitive but not necessarily specific should not be dismissed but should instead be followed up, potentially by analysis of the clinical databases. The sheer volume of useful data contained within the administrative dataset, in some ways greater than that stored in clinical databases, and certainly far greater than that of RCTs, make it wrong to dismiss the findings of administrative dataset outcomes research. In the UK, HES data has been analysed and publications produced in the areas of mortality after fractured neck of femur, outcome after total hip replacement and the incidence of pulmonary embolus after joint replacements8-10. The recently published GIRFT report11 states, “With a projected NHS savings requirement of £20 billion by 2015, against a background of an ageing population with an increasing requirement for orthopaedic
treatment, there must be an attempt to address provision of care which accounts for 80% of the total cost”. We in the UK are not alone in this predicament. Health service provision worldwide is under severe strain. The Organisation for Economic Co-operation and Development 2014 report states that health spending across OECD countries is a mean of 9.3% of GDP and is rising. However, there are vast differences. For example, in the USA, healthcare accounts for 16.9% whereas for the UK and Australia it is 9.3% and 9.1% respectively. Are the clinical outcomes different in each country? Are we treating vastly different populations? Are we getting value for money? Until recently it was difficult to attempt to answer this question as international comparison using these vast datasets was not possible. However, recent collaboration between countries has been attempted. Dr Foster Global Comparators started in 2010 with the aim to bring together data from hospitals in different countries, translate the data into a common language, commence research and compare the results openly. This is only possible however when clinicians and healthcare providers share their knowledge and understanding in order to improve patient outcomes; a goal championed by Lord Darzi in the >>
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JTO Peer-Reviewed Articles
There remain considerable challenges when combining administrative databases, nevertheless it is possible to define in-patient admissions, diagnostic and procedure groups as well as adjust for co-morbidity and produce risk adjustment models.
foreword to the GIRFT report. Currently there are six Global Comparators (GC) groups; including Gastrointestinal (GI) surgery, Health Economics and Orthopaedics. Global Comparators started with 31 organisations in five countries which have grown to 45 organisations in ten countries. Each hospital within GC provides HES type administrative datasets which are analysed and validated at Imperial College, London. The initial international dataset contained 6.7 million anonymised inpatient records and currently has 20m anonymised inpatient records. There remain considerable challenges when combining administrative databases, nevertheless it is possible to define in-patient admissions, diagnostic and procedure groups as well as adjust for co-morbidity and produce risk adjustment models12. Currently in The Orthopaedic GC group we are comparing international outcomes following fractured neck of femur and the effectiveness of revision surgery for prosthetic joint infection in both hip and knees. The numbers of patients analysed in this research is over 55,000 and administrative data is available from four countries. We are currently validating our comorbidity score modelling before statistically analysing the
international outcomes data. However, we do hope to have manuscripts for publication within the next month and look forward to peer review. As for the future, by measuring comparative outcome data, be that at national or international level it is possible to provide meaningful analyses of therapeutic intervention incorporating provider and patient variables. Outcomes research may then be in a position to accurately permit analysis of cost benefits (net costs), cost effectiveness (net cost per net change in years of life) and perhaps most importantly in orthopaedics; cost utility analysis, the net cost per net change in quality of life. Performing this at an international level, with the support of clinicians and healthcare providers may generate meaningful hypotheses as to how to deliver excellent patient outcomes and address realistic provision of care in increasingly austere times. I would like to acknowledge Dr David Chang, Associate Professor of Surgery, Massachusetts University Hospital, Harvard Medical School and The Orthopaedic GOAL group, Dr Foster Global Comparators Project, Imperial College, London for their guidance.
Andy Gordon is a revision hip and knee surgeon at Sheffield NHS Teaching Hospitals Foundation Trust. He obtained his PhD in immunobiology and the genetic risk factors for aseptic loosening after total hip replacement. He is currently Vice Chair of the Dr Foster Orthopaedic Global Comparators Group.
Correspondence Email: andrew.gordon@sth.nhs.uk
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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Sponsored Content – Sponsored Content Training and Recruitment MEIbioeng15 is the UK’s largest ever gathering of biomedical engineers, bioengineers and medical engineers, with participants from leading academic centres and the MedTech industry. The conference is a two day event taking place on 7th & 8th September 2015 at the University of Leeds.
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and Elbow Surgical Approaches 10th September l Principles of Hand & Forearm Surgery 11th September l Principles of Forefoot Surgery - 6 October In addition to these courses we are also planning for 2016: Hip and Knee Arthroplasty, Shoulder Arthroscopy, Knee Arthroscopy, ACL reconstruction, Surgical approaches to the spine.
Objectives of the day: l To develop consensus pathways for shoulder arthroplasty l To agree on actions to reduce variations in practice and optimise outcomes Presentations and discussion sessions to cover: l National Joint Registry and PROMs for shoulders l Evidence informing current
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surgical procedures for shoulder arthroplasty l Guidance on implant and procedure selection l Standardising physiotherapy and rehabilitation pathways l Developing a shoulder dashboard Delegate Fee: £60 To register please contact: Email: info@oruk.org Tel: 020 7637 5789
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JTO Peer-Reviewed Articles
© 2015 British Orthopaedic Association
How I... Use Blocking Wires to Nail Proximal Tibial Fractures Ishvinder S Grewal, Peter Bates
Modern nailing systems have sufficient locking options, proximally and distally, to allow stable intra-medullary fixation of short-segment metaphyseal fractures. However, malreduction (particularly of the proximal tibia) after nailing is still common since metaphyses lack the cortical fit of the diaphysis, giving them less intrinsic alignment when nailed 1,2. ‘Poller’ (German for bollard) screws and wires have been used to prevent such malreduction, by applying three-point fixation on the nail, effectively reducing the diameter of the medulla 3,4,5. Our preferred technique for metaphyseal blocking uses poller wires (2mm or greater), which are removed after locking. Wires are preferable because: -If misplaced slightly, they are easy to redirect, fine-tune or use as reference for a second wire. -They are more flexible when trying to pass the nail. Blocking screws are bulky, definitive and less forgiving, which increases the likelihood of fracture as the nail is ‘bullied’ past.
Tendency for mal-alignment The typical deformity seen is valgus and apex anterior (Figure 1-2, far left). Techniques such as accessory plating and semi-extended/supra-patella approaches are well described but are not discussed here. The importance of a good entry point is critical – high up on the tibia (lateral view) and just medial to the lateral tibial spine (AP view) 3,4.
The technique (Figures 1-2) 1. The tibia is reamed, measured and nailed in the usual way, with emphasis on the entry-point. 2. The deformity is then noted (typically valgus and apex anterior). 3. In the proximal tibia, blockers belong on the concavity of the deformity 4. Blocking wires (we use 3.2mm) are taken down onto the nail 5. The wire is backed off slightly to allow the nail to move 6. The nail is knocked out and the wire is advanced to the far cortex 7. The nail is re-inserted Once reduction is achieved on both views, the nail is locked with three or
Figure 1: Correction of deformity on the lateral view (apex anterior) Left: Nailed with apex anterior deformity. A 3.2mm wire is passed from medial to lateral. Mid: Nail withdrawn - A 3.2mm wire is passed from medial to lateral until it hits the nail. The wire is now blocking the path that the nail previously took. Right: The nail is re-inserted and the position checked. The process can be repeated several times with minor adjustments to wire position each time. Alternatively, a second wire can be placed, using the first as a reference and hitting the nail a second time, before repeating the process.
more screws and wires are removed. Commonly held belief – blocking screws have to be left in place as part of the fixation. In our experience, with three or more locking screws through the nail, this is not the case. We only occasionally replace our wires with screws.
Comment – training and experience The use of wires (rather than screws) is elegant, since they are much more forgiving and easier to adjust and get just right. The technique described is excellent for those less familiar with poller techniques. It is also superb for training, since the surgeon doesn’t have to know the exact spot where to put the blockers in advance. With experience, one gets a feel of where blockers need to go, making it reasonable to place them pre-emptively, before the nail goes down, leaving the option of adjustment/fine-tuning.
Ishvinder S Grewal
Peter Bates
Ishvinder is a 3rd year Orthopaedic Registrar on the Royal London Orthopaedic Rotation. He graduated from Imperial College London in 2008 before completing his junior doctor training in Liverpool working
Figure 2: Correction on the AP view Left: The nail is down and a valgus deformity exists. A 3.2mm wire is passed front-to-back onto the nail. Mid: The nail is backed out and the wire is advanced. The wire is now sitting/blocking where the nail previously was. Right: The nail is sent past the wire.
mainly at the Royal Liverpool Hospital. He has an interest in Lower Limb Trauma and Reconstruction and also in Lower Limb Sports Surgery, working with professional athletes in his capacity as a ringside surgeon for the British Boxing Board of Control, often for televised contests. Peter Bates is an orthopaedic trauma surgeon at the Royal London Hospital (Barts Health). He was a Stanmore trainee and completed various trauma fellowships internationally. His subspecialty interest is pelvic and acetabular fractures and polytrauma and his favourite foods include curry and burgers. He was the 2014 BOTA trainer of the year and he has a serious dislike of beetroot (a hangover from school).
Correspondence Email: peter.bates@bartshealth.nhs.uk Email: ishi@doctors.org.uk References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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Sponsored Content – Sponsored Content Training and Recruitment The 14th Oswestry Foot and
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Mechanics is the study of the effects of load on an object, i.e. what the load is doing to the object and how the object is responding to the load.
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In Memoriam
James Tulloch Brown James Brown was born in Hamilton, Lanarkshire and educated at Hamilton Academy before studying Medicine at Glasgow University.
orthopaedic surgeon who saw his potential and encouraged him to study for his surgical fellowship after the War. He gained his Edinburgh Fellowship in 1946 while working as RSO at Killearn Hospital with Professor Roland Barnes. In June 1948 he was appointed as Consultant Orthopaedic Surgeon to the Western Infirmary Glasgow.
He graduated in October 1938 and did House jobs at the Victoria Infirmary before joining the RAMC in 1939 at the age of 24. His initial posting to France ended with the Dunkirk evacuation. In 1940 he was attached to the 21st Mobile Casualty Clearing Station. This Unit supported the Dessert rats in their North African campaign through Egypt, Sicily and the Italian landings. By 1944 he was attached to the 5th Orthopaedic Centre, involved in treating of the wounded from the battle for Monte Casino. His ‘boss’ at the hospital was a female American
JTB was an outstanding orthopaedic surgeon, one of a very highly respected team who, during the 25 years after the War, developed and then established Orthopaedic surgery in the Western Infirmary, where previously it had not existed. He was an excellent teacher and a junior staff training attachment to him was highly prized. He invented two surgical devices for fixing hip fractures. The first, the sliding nail plate, was adopted in 1957 to provide improved stability compared to the single SmithPetersen trifin nail. It was widely
29th May 1915 – 15th December 2014
James Tulloch Brown
John Goodall
10th April 1960 – 20th January 2015 John Goodall was born in Aldershot. His family moved to the South coast, spending his younger years in Shoreham. He developed a love of sailing and became an active member of Shoreham Yacht Club. He spent many weekends sailing the family yacht with his father and brother, Peter.
John Goodall
He enjoyed painting the landscapes of the South Downs. It was this love of landscape paintings that led him to meet Kate who also loved to paint. They were both working in the accident department of the Royal Sussex County Hospital in
Brighton. Their love of painting blossomed into a love for each other and they later married. After secondary school John entered St Mary’s medical school where he qualified as a doctor. John decided that Orthopaedics was to be his future. He was appointed to the St Mary’s training scheme where he forged many strong friendships among his peers and fellow trainees. He was appointed to Central Middlesex Hospital in 1996. He developed an interest in spinal surgery. He approached his patients in a truly holistic fashion. Surgery was nearly always the treatment of last resort. This attitude to his patients and work was strengthened by his strong Christian faith. His faith led him to conducting prayer meetings
used with success and the results published in the JBJS in 1964. He retired in 1980 to live in Lochmaben, Dumfries, with his widowed mother. This ideal location allowed him to indulge his favourite hobbies of salmon fishing and sailing his yacht around the West Coast. His other hobbies were photography and wood turning, utilising his own darkroom and workshop. The quality of his pictures, mainly land and seascapes, was exceptional. He will be remembered as a highly independent, deep thinking and private man. The full length obituary can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.
with other members of staff on a regular basis. He will also be remembered for the love of his dogs that he regularly brought to fracture clinic. On one occasion an articulated skeleton had to be rescued from one of them who fancied a nice bone to chew on! John became ill just over four years ago and bore his condition and treatment with characteristic bravery. He retired on grounds of ill health. He, Kate and his daughter Anna joined a Bible college in Walsall. When John passed away it was a shock to all who knew him. He died in peace with his family at home. He will be greatly missed.
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In Memoriam
Gamada Ergate Ayana 25th February 1973 – 8th February 2015 Gamada was born in Ethiopia and brought up in Greenock. He graduated from Glasgow University in 1995, completing basic surgical training in the West of Scotland before being appointed to the orthopaedic training programme in 2001. He developed an interest in shoulder surgery and was appointed a consultant at the Royal Alexandra Hospital Paisley in 2007.
Gamada Ergate Ayana
Gam brought energy, enthusiasm and commitment to all aspects of his career. As a trainee he will be best remembered for turning the
annual trainee’s dinner into a “must attend” event. As a consultant, as well as being a much respected clinician, he was a fair and respected clinical lead with an ability to mix humour and authority in a way that only he could. He was an excellent clinical teacher and attachments with him became one of the most sought after on the training programme. He was West of Scotland trainer of the year in 2014. His commitment and pertinent comments and observations made him a highly respected member of the local
training committee; a fact recognised in his being voted its Chairman. Away from work he enjoyed live music, travel, and spending time with friends and family. He made an outstanding contribution to training in the West of Scotland. His premature death from metastatic carcinoma of unknown primary robs the region of one of its most charismatic and energetic trainers. He will be sadly missed by trainers and trainees alike. He leaves a wife, Rosy, and a son Luca (aged 22 months).
Andrew Sprowson
27th March 1974 – 13th March 2015 Andrew Sprowson was tragically killed in a road traffic accident on 13th March 2015. He was 40 years of age and is survived by his wife, Louise and two children aged 6 and 9.
Andrew Sprowson
Andrew Sprowson was a consultant trauma and orthopaedic surgeon at the University Hospital in Coventry, and an Associate Professor of Orthopaedic Surgery at Warwick Medical School. He had a special interest in cartilage repair and is co-author of the UK consensus document on cartilage repair.
He was jointly appointed at the University of Warwick and the University Hospitals of Coventry and Warwickshire NHS Trust (UHCW) in April 2012, having completed his orthopaedic training in Newcastle, Middlesbrough and Australia. He immediately began to establish himself as a clinician and researcher, developing and implementing new techniques in knee surgery.
and international meetings, and had been selected to travel around the world as a talented orthopaedic leader to represent the British Orthopaedic Research Society.
He inspired and taught young doctors and researchers alike, and helped to lead the Masters course in orthopaedic surgery. Andy was well known across the country: he was a regular speaker at national
To everyone who knew him, he was ‘larger than life’ and an exceptionally enthusiastic, bubbly character, who loved to work hard and make new and exciting things happen.
Andy was a keen runner and ran the London Marathon in 2009 to raise money for Joint Action, the research fundraising arm of the BOA.
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Imprint
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JTO is published quarterly.
Word Limit
News stories should be no longer than 250 words. Articles about Specialist Society meetings should be no longer than 250 and must include an image. We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 200 words and should include a photo. Feature articles and Peer-Review articles should be no longer than 1,500 words. Please be aware that the Editorial Team reserves the right to reduce the content where appropriate. References are not included in the word count but will be included separately on the BOA website in the JTO section and will not be included in the print version of the journal. References should be supplied in the Oxford Referencing format.
Images
All articles should include images, illustrations, graphs, tables etc. where possible – this is strongly encouraged. These, however, should not be embedded into the article but should be sent as separate image files to the JTO team with clear file names pertaining to figure numbers or the image title. An indication within the article should identify where the image should be inserted. The article should state a short title/caption for each image. Please note that it is the responsibility of the author/s to obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere.
Peer-Review
Peer-Review articles will be reviewed by two or more (where appropriate) independent reviewers following a review by the Editor. You may be asked to revise your article following this process and you will be provided with the reviewers’ remarks to help you with this.
Important items to note
You must submit with your article and images; a photo of yourself and a short bio in the third person (no more than three sentences). You will be sent a Copyright Form following your article submission and this should be returned by email (signed, dated and scanned) to JTO@boa.ac.uk or posted to JTO Team, BOA, 35-43 Lincoln’s Inn Fields, London WC2A 3PE.
How to subscribe If you’d like to subscribe to future issues either for yourself or your organisation, we’d be happy to add you to our mailing list; please contact us at JTO@boa.ac.uk Please note all issues are free of charge.
Advertising All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820
Disclaimer The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication. Readers are warned to take specific advice or make individual assessments to deal with specific cases or situations. Health professionals should be aware that ultimately it is their responsibility to make their own professional judgements.
Special thanks We are grateful to the following for their contributions to this issue of the Journal: John Nolan, Richard Parkinson, Colin Bruce, Charlotte Lewis, Alwyn Abraham, Lee Breakwell, David Hamblen, James Graham, John Hollingdale, David Large & Tim Spalding.
Copyright Copyright© 2015 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C
BOA contact details The British Orthopaedic Association 35-43 Lincoln’s Inn Fields London WC2A 3PE Telephone: 020 7405 6507 Fax: 020 7831 2676
Erratum • The ‘When Two Become One’ article in the last issue should have stated that Will Cobb was the main author instead of Paul Gibb • Contributing authors for the OCL article in the last issue were C M Blundell, A Ali, J W Croft