BJJ News Issue 1 by BoneandJoint

BJJ News

Formerly known as JBJS (Br)

BJJ News | I ssue 1 | O ctober 2013

Issue 1

Editorial

Here is the (BJJ) news elcome to BJJ News where you will find articles about aspects of orthopaedic surgery and orthopaedic surgeons which complement the scientific pages of BJJ.

It’s a big world out there involving tremendous activit y by or thopaedic surgeons and their teams. Not only do they carry out the day-to-day care of patients but also go the extra mile by developing innovative techniques, teaching, organising meetings, courses and fellowships, working with government, doing charitable work and serving their community. A considerable number also possess extraordinary talents outside the realms of orthopaedic surgery. BJJ News aims to reflect this. We will present historical aspects of the development of our specialty, from which there are always lessons to be learned. We will try to report all these efforts from around the world in an informative and enjoyable way: in this first quarterly edition of BJJ News we set out our stall. Among the pages you will find a critical analysis by Paul Gregg of the way in which National Joint Registry data is being used to assess individual surgeons (p2), reports of various meetings, fellowships (p22-25), a trainee corner (p17), reminiscences of happier times (p5), a letter requesting a section on surgical tips and tricks (p28) and a profile of an orthopaedic surgeon with a phenomenal parallel career in a completely different sphere (p26).

Of particular interest, we publish a section called Bridging The Gap where we confirm the view that or thopaedic surgeons worldwide are generally a charitable bunch whose contributions, whether on a large or small scale, do much to bridge the gap between resources and need. We also report examples of how and where charitable orthopaedic activity has helped to improve the lives of patients less fortunate than ourselves. In this edition we highlight two large-scale success stories from India. The story of Ganga Hospital is already known to many and now, through its Founder’s Lecture, allows us to appreciate the visionary achievements of Dr Devi Shetty (p19). We also report on the efforts of SICOT and WOC in their attempt to improve training in underprivileged countries (p21). There is much news t o sh are and we , at t he f ledgling BJJ News, will be receptive and f lexible in our r e s p o n s e t o s u b m i s s i o n s . Wr i t e to bjjnews@boneandjoint.org.uk and tell us what’s going on out there!

In this issue: Political comment

Public reporting of the outcome of total joint replacement P. Gregg

Consensus report

Innovations in knee surgery R. F. Kallala, M. S. Ibrahim, F. S. Haddad

Bridging the gap

Ganga Hospital: vision and mission S. Rajasekaran David Jones

Alistair Ross Editors

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BJJ News

Issue 1

Journal Office:

Advertising enquires:

Edited by:

22 Buckingham Street, London

Dr Pam Noble

Mr David Jones

WC2N 6ET, UK

ADmedica

Consultant Or thopaedic Surgeon, Retired

bjjnews@boneandjoint.org.uk

pnoble@admedica.co.uk

Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath

October 2013 2

Political comment Public reporting of the outcome of total joint replacement P. Gregg

Orthopod’s view Reflections on a life in orthopaedics F. T. Horan

18 Ganga Hospital: vision and mission

Deciding a price tag for human life

Notes from the road

12 International Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip P. E. Beaulé 13 Current Concepts in Joint Replacement® A. Seth Greenwald 14 Evolution of The Hong Kong International Wrist Arthroscopy Workshop and Seminar P. C. Ho, C. Wong

D. Shetty

21 Orthopaedics in an unequal world

M. Laurence

Fellowships

22 American-British-Canadian Travelling Fellowship 2013

S. Rajasekaran

19 Ganga Hospital Founder’s Lecture:

Consensus report Innovations in knee surgery: the London Knee Meeting 2012 R. F. Kallala, M. S. Ibrahim, F. S. Haddad

Bridging the gap

J. M. Wolf, A. Yee, B. Wolf, et al

24 Austrian-Swiss-German Travelling Fellowship 2013

T. Renkawitz, A. Niemeier, F. von Knoch, R. Biedermann

Orthopod profile

26 Dr PC Ho: Renaissance Man

D. Jones

Letters

28 Every little helps

Trainee corner

17 BOTA Conference J. Palan

N. Jayasekera, T. Hunter

Is it all in the name?

N. A. Ferran

A Bone & Joint Publicat ion THE BRITISH EDITORIAL SOCIET Y OF BONE AND JOINT SURGERY. Registered charit y no: 209299. All ar t icles within BJJ News are published under the Creat ive Commons Attribut ion License (CC-BY 3.0)

BJJ News | I ssue 1 | O ctober 2013

Political comment

Public reporting of the outcome of total joint replacement

n the publication from the NHS Commissioning Board, entitled “Everyone Counts: Planning for Patients 2013/14”, it is stated that the NHS Commissioning Board will provide five offers to NHS Commissioners to give them the insights and evidence they need to produce better local health outcomes. Offer 2 is entitled “More Transparency, More Choice”. It is stated that it is critical for patients and Commissioners to understand the quality of services being delivered within hospital and other health care settings. To enable this, with oversight from our national Medical Director, the Health Care Quality Improvement Partnership (HQIP) will develop methodologies for case-mix comparison and, in conjunction with NHS Choices, publish activity, clinical quality measures and survival rates from National Clinical Audits for every Consultant practising in a list of ten specialities, including orthopaedic surgery. The data was to be published by the summer of 2013. Commissioners were instructed to ensure that each of their providers published its own information on these specialties on its website in a format defined by HQIP. Publication will be part of the NHS Standard Contract for 2014/15 to allow for comparisons across hospitals. The document further states: “This work is a ground-breaking step towards ensuring the rights and pledges set out in the NHS Constitution are delivered, including a patient’s right to choose the most appropriate setting for care. This means choice both at the point of GP referral and along the care pathway. Choice and competition incentives are important in so far as they contribute to achieving better outcomes for patients and local communities”. Because the National Joint Registry (NJR) is part of the HQIP portfolio of activity, it was inevitable that the NJR would be used as a vehicle to obtain data on the outcome of joint replacement for the purposes of this initiative. It is, therefore, perhaps useful to review some

of the aims and thinking surrounding the establishment of the National Joint Registry in 2002/3. THE NJR CONSULTATION DOCUMENT

In October 2000, the Department of Health issued a “National Joint Registry Consultation document”. In this were noted the reports in April 2000 by the National Audit Office and National Institute for Clinical Excellence who identified: “Evidence for long term effectiveness of hip implants was not available for those implant types in current use and recommended the establishment of a National Hip Registry”. The objectives of the National Joint Registry were primarily to ensure that

P. Gregg

nurses who could directly check a sample of incoming data with theatre records and inpatient procedure records, in order to validate the data”. This was something that had been used in the Trent Regional Arthroplasty Registry, which I established in 1990. Furthermore, the consultation document included: “Orthopaedic surgeons at a local hospital level require feedback on their performance. It is likely that the publication and data in the form of league tables, with no reference to complex issues such as case mix, may discourage surgeons from contributing data to the NJR. It is therefore proposed that the NJR is organised to give surgeons at each hospital confidential feedback on their own performance, compared with their

Registration of cases with the NJR has been compulsory since 2011 patients obtained optimal clinical care during and after joint replacement operations. The second was to ensure that the NHS and other health care resources were used to the best advantage. The third was to help improve surgical practice and the fourth to provide patients, clinicians, health care purchasers/ commissioners, regulators and manufacturers with evidence for the best performing implants. Among the several objectives outlined were: “Promote open publication of performance of implants to improve awareness” and “To monitor comparative performance of hospitals”. It is noteworthy that nowhere was it stated that there should be open publication of surgeon performance; the emphasis was very much on the implant. In further scene setting, it is worth noting other statements from the consultation document, which include: “We propose that a national co-ordinating centre should be supported by four or more mobile or peripatetic

wider local area and national performance”. It is clear that, at that time, league tables were not supported. I think we would all agree that the suggestions in the consultation document were eminently sensible and, given the fact that the registration of cases with the NJR was not compulsory, in my opinion a serious mistake when setting up the NJR, the majority of orthopaedic surgeons voluntarily registered their data in good faith. The emphasis was ver y much on the monitoring of implant and comparative hospital performance and not individual surgeon performance because of the difficulties associated with this. MEASURING SURGEONS’ PERFORMANCE

It was perhaps inevitable that, at some stage, consideration would be given to measuring surgeons’ performance in terms of mortality

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and revision rates, albeit with the acceptance that measuring revision rate alone does not necessarily give a reliable picture of the individual surgeon’s performance. It was, however, the only indicator available to us at the time until the more recent introduction of PROMs on a national basis. However, these are flawed by the fact they are only collected up to six months after surgery and experience has shown that 50% of returns are unreliable. The current system involves the calculation of the standardised revision ratio (SRR) for hip and knee replacements for individual surgeons, presented as a funnel plot. Those surgeons whose SRRs are above the 99.8% confidence limit from the national mean are classified as “potential outliers”. These results are reported to Hospital Trusts, Welsh Boards and Group Chief Executives of private providers in the form of the “Annual Clinical Report to Trusts” and the data are reviewed six months later. If new potential outliers are identified, further reporting takes place. The Annual Clinical Report to Trusts does not name any surgeon but the Chief Executive is notified separately in a confidential letter. Furthermore, the potential outlying surgeon is notified six weeks before the report goes to Trusts to allow for some validation of the data. Also, the letters which are written to Chief Executive Officers make it very clear from the outset that the status of an outlier is a statistical one and based purely on the data held for that surgeon, which may or may not be complete and that there could be many reasons for the potential outlying status such as implant selection and case mix. The important aspect about this system is that the surgeon has prior knowledge of their potential outlying status with the opportunity to validate or challenge the data prior to any questioning from the Chief Executive/Medical Director. Experience to date shows that this system works relatively well. The status of outlier has often been found to be due to incomplete data submission and/or use of implants that are known to have a high revision

rate. Furthermore, this system should only be regarded as a trigger for an internal audit of the surgeon’s performance because only this, with access to case notes and radiographs, can result in a true judgement of whether there is concern about the standards of the joint replacement surgery. I firmly believe that this system can and does work well in most instances and should, if treated correctly by the individual Trust, give adequate safeguards in terms of patient safety. This system should also improve, given the fact that registration of cases with the NJR has been compulsory since 2011, although, in my opinion, the monitoring is still inadequate. This situation may be improved by the incorporation of NJR compliance into Payment by Results. THE EFFECT OF THE ‘EVERYONE COUNTS’ INITIATIVE

It was only in December 2012, that NHS England (then the NHS Commissioning Board) announced that through the “Everyone Counts” initiative, the activity and outcomes of surgery at individual consultant level would be published by 30th June 2013 in ten clinical areas, of which orthopaedic surgery was to publish data for total hip and total knee replacement. The NJR, as the appointed National Clinical A u d i t , w a s i nv o l v e d t o s u p p o r t t h e corresponding professional body, the British Orthopaedic Association (BOA), in meeting the requirements of the initiative. The process of publication across all ten clinical areas was managed and guided by HQIP. I was led to believe that the first time the NJR heard of this initiative was a casual remark at a meeting attended by a member of the HQIP/NJR team and the Department of Health/NHS England in late December 2012. To my knowledge, the BOA was unaware of this initiative at that time. Given that the data was to be made public by the end of June 2013, this gave an extremely tight timeframe in which to work. Furthermore, to the best of my knowledge, there had been no

prior consultation with either the NJR or BOA in relation to the complexity and potential problems that might be associated with this. The process was further complicated by the fact that the Department of Health/NHS England had assumed that consent from surgeons would not be required but, perhaps not surprisingly, it transpired that it would be checked and appropriate. This necessitated complex and time-consuming consent processes run by the NJR and BOA. Surgeons were offered three options: 1 Consent to publication of consultant level activity and mortality data. 2 Consent to publication of consultant level activity data only. 3 No consent to publication of consultant level activity and mortality data. It should further be noted that if no consent option was recorded within the 14 days, (the consent process was set up, online, by HQIP), surgeon level indicators, including the mortality, would be released under the mandate of NHS England. In the opinion of the author, this equated with an “opt out” rather than “opt in” system. It is, perhaps, noteworthy that we were not allowed an “opt out” system for patient consent for data entry into the Registry, as operates in the Australian Registry. Problems with the consent process resulted in it having to be extended until 21 June 2013, ten days before the date for publication of surgeon outcomes. THE RESPONSE OF THE PROFESSION

In view of the lack of consultation with the or thopaedic profession prior to the announcement of this initiative, the BOA sought an urgent meeting with representatives of NHS England, which was attended by representatives from the BOA, NJR, British Hip Society and British Association for Surgery of the Knee. Thankfully, our concerns were ►

BJJ News | I ssue 1 | O ctober 2013

listened to, as a result of which it was decided that only case numbers and mortality would be published in the first instance and not hip and knee replacement revision rates. There was still concern regarding the publication of mortality data without appropriate risk adjustment. It was fortunate that no surgeon was classed as an outlier in the publicly reported data. However, it should be noted that two surgeons initially appeared as outliers and they were informed of this. It was later found that their data had not been risk-adjusted for hip replacement for fractured neck of femur or metastatic disease. Not surprisingly, this caused great distress to the surgeons and almost certainly resulted from the ridiculously short time-scale that existed for the publication of these results. It would appear that only a very small number of orthopaedic surgeons withheld their consent, principally on the grounds of data completeness and quality concerns. However, it is not clear whether all of the other surgeons actively opted into the process or simply were opted in by default, through failure to respond within the 14-day period. The reassuring news from this initiative is that primary total hip and knee replacements are very safe operations with an extremely low mortality rate despite the fact that they are now carried out in the elderly, very elderly and in those with significant co-morbidities. While mortality rates may be a very good primary outcome measure for higher risk surgical procedures, such as cardiac or vascular surgery, in the case of total hip and knee replacement mortality rates are more heavily influenced by many factors other than technical aspects of the surgery itself. It is therefore inappropriate to judge the quality of such surgery based solely on mortality rates. Case mix adjustment is a useful tool but as with any methodological approach, it cannot account for all differences, including those that may be due to random events. It is therefore questionable as to the value to the patient of publishing these results. It is inevitable that expansion of this policy will involve the use of revision rates as primary outcome measures for replacement surgery of the hip and knee. For this, data completion and accuracy are paramount, particularly in relation to the publication of the results of individual

surgeons whose number of procedures may be relatively small and, therefore, cases which are not registered may have profound influence on the revision rate. It is regrettable that the Department of Health did not make registration compulsory at the inception of the NJR in 2003. When I was President of the BOA, I tried unsuccessfully to influence the Chief Medical Officer to do this but it was not introduced until 2011. Therefore, the data upon which the Registry calculates revision rates includes several years when data collection was not compulsory and consequently incomplete. This could result in a situation where surgeons who withhold data registration, for example about cases of revision, would not be identified as potential outliers. This is unfair to those who have diligently entered their data and the overall results will also mislead the public.

espite many personal pleas over the years to introduce a system of robust validation of compliance with the NJR, it is regrettable to report that this has, so far, been unsuccessful. More recently, as Chairman of the Data Quality Committee, I wrote to the Chief Executive Officers of all Trusts, Welsh Health Boards and private sector groups requesting that we receive the name of an individual within their organisation to whom we could send data for validation on an annual basis. It is disappointing to report that of the 151 letters written, we received a response from only approximately 50%, despite two letters being sent. It is my personal view that, unless this situation can be rectified as a matter of urgency, perhaps with help from NHS England, the surgeon outlier process should be put on hold until a reliable method of data validation is established. In this context it is noteworthy that the President of the Royal College of Surgeons of England stated, in a recent bulletin “We have insisted that only national audit data should be used, that no outliers should be identified without the data being carefully checked, that appropriate risk stratification is in place and that we control the narrat ive for public understanding”. On a separate issue, it is hoped that, with the publication of individual surgeon outcome data, surgeons do not become more risk adverse

and limit the number of operations undertaken by trainees: these have already decreased significantly since the introduction of the European Working Time Regulations (EWTR). It is critical that monitoring systems, using the trainees’ electronic logbook, are established to ensure that surgical training is not adversely affected by the publication of individual surgeon outcome data. With patient safety paramount, I believe the mechanisms which have been developed within the NJR, and continue to be developed, should achieve this satisfactorily. In the event that the publication of surgeons’ revision rates is forced upon us, this must not happen until much more rigorous mechanisms for data validation are in place. These should include, as recommended in the original consultation document, regular visits to hospitals and inspection of their operation records to crosscheck with the data held by the NJR. This will also require Chief Executives to take the NJR much more seriously than is apparently the case, in order to ensure adequate audit support within Trusts for complete data entry. The other issue, apart from patient safety, is the need to provide patients with information to allow them to make an informed choice about joint replacement surgery. I would seriously question whether the imminent publication of caseload and mortality data helps them at all and the crude reporting of standardised revision ratios, even if accurate, is unlikely to be of any real value. In order to make this initiative useful for patients, there surely needs to be a detailed dialogue with them in order to establish the nature of the information that they would most wish to see. Surprisingly, to the best of my knowledge, this has not yet taken place! It is, perhaps, also noteworthy that no significant work has yet been done on the development of methodologies for case mix comparison as required by the NHS Commissioning Board publication. A uthor

details

P. Gregg

Vice-Chair, NJR Steering Committee prof.gregg@btinternet.com

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Orthopod’s view

Reflections on a life in orthopaedics

F. T. Horan

Frank Horan, retired orthopaedic surgeon and former Journal Editor reflects on his life in orthopaedics became an orthopaedic surgeon through the influence of George Bonney and John Craw ford Adams at St. Mary’s, where I was a student. They alternately held a teaching round on Saturday mornings at 9.30. This was very convenient for me, since I was then able to have a coffee and a cigarette before setting off to whichever ground where I was playing cricket, rugby or soccer in the afternoon. I was impressed by the considerable trouble which they took to teach us to examine the patients with care and courtesy, and then to explain with clarity and simplicity the diagnosis and the problems involved in management. This attracted me to the specialty and I was determined to attempt to follow in their footsteps. Pathways for training were then illdefined. In 1960 I became a house surgeon in plastic surgery and orthopaedics at the West Middlesex. I then progressed to be a casualty officer at St. Mary’s before being appointed to an SHO post at the Royal National Orthopaedic Hospital. The next step was to complete two years in general surgery, which I did as a registrar at St. Albans, where I obtained the FRCS. My next orthopaedic post was at Barts, where I was registrar to Charles Manning. There was then no clear way to proceed. The rotating schemes at registrar and senior registrar had not yet been introduced, although they came in shortly afterwards. I took a post as chief resident at the Montreal Children’s Hospital, followed by a Canadian MRC Fellowship in the Bioengineering Department at McGill. I had no job to return to in England, but always had the ambition to be a senior registrar at St. Mary’s. After months of locum work I was finally appointed to this

post, which alternated with Northwick Park. I enjoyed this job enormously and was eventually appointed as a Consultant at Cuckfield Hospital in Sussex. I was fortunate to be able to compare the systems for training in the UK and in North America, where the programmes were carefully structured with regular and planned rotations. There was a greater emphasis on an academic approach with tutorials to cover most aspects of orthopaedics with particular attention paid to pathology. The trainee was expected to carry out a clinical research project and present the results at local meetings. The object in Canada was to prepare for the Canadian FRCS in orthopaedics, which was necessary in order to practise in that country. When I returned to the UK in 1971, following a review by the British Orthopaedic Association (BOA), a more formal structure had been put in place which was similar to that in North America and plainly a considerable step forward. Subsequent reviews of training improved on this, with courses and journal clubs leading to the FRCS (Tr & Orth) examination. However, the imposition of the European Working Time Directive has seriously interfered with adequate training. We are not yet in a position to judge the long-term effects of this, although it is difficult to see how a thorough training can be achieved in the time available. This will inevitably encourage even further super-specialisation, which may raise standards, but will require further re-organisation of the Health Service to allow the formation of fewer units, as is already occurring. The days of the ‘general orthopod’ are long past. But what of the practice of orthopaedics? This has changed almost beyond belief. We are still dealing with similar pathology but

the methods of diagnosis and management have advanced greatly. The advent of the CT scanner, and latterly MRI, have allowed major progress in the accuracy of diagnosis and planning of operations, but their increasing use appears to have lessened the need for the taking of an accurate history and a proper physical examination. This is partly due to intellectual laziness and partly to the enhanced expectations of the patients who feel entitled to the automatic use of such expensive investigations. There is, however, little doubt that they have facilitated great improvements in the management of all aspects of the specialty. The BOA has campaigned for improvement in the management of acute trauma for many years. Various presidents have petitioned the Department of Health for the establishment of trauma centres, and have usually been ignored. At last the organisation of trauma care is beginning to be arranged properly and the experience gained in recent wars is being utilised. There is no place for smaller district hospitals in the care of all but minor trauma. An ag gressive approach has replaced the more conservative attitudes of former years. There is better understanding of the metabolic aspects which, together with improvements in the design and manufacture of implants, have allowed more precise surgery and earlier mobilisation. It is perhaps in the management of the degenerative joint that the most striking progress has occurred. When I came into orthopaedics, the standard treatment for osteoarthritis of the hip was an upper femoral osteotomy or, in some centres, a cup arthroplasty. In extreme circumstances an excision arthroplasty, a Girdlestone procedure, which had previously been ►

BJJ News | I ssue 1 | O ctober 2013

Perhaps the most dominant feature of this period has been the continual and stifling interference at government level

Frank Horan (top row, centre) St. Mary’s Hospital ‘B’XV, 1964

employed for tuberculosis of the hip, was utilised. The advent of joint replacement, pioneered by McKee and Charnley, allowed the relief of pain and restoration of mobility. This has probably been the most lifeenhancing procedure ever devised. The principle of replacement of a worn joint has been applied to other sites, particularly the knee, and has brought great relief to many patients. The relief of the painful back has been greatly improved by modern operative surgery aided by better anaesthesia and better design of implants. I m prove me nt s in a n ae s t he si a a nd the understanding of the need for early mobilisation have enhanced the speed of recovery and decreased the time that patients need to remain in hospital. This has also been driven by economic factors which have required costs to be kept to a minimum and have encouraged more active management. I am not convinced that there has been any notable improvement in the general care of the patients at ward level. The introduction of Project 20 0 0 and the abolition of the training and rank of the State Enrolled Nurse, have, together with an apparent change in the role of the ward sister, resulted in a lessening of responsibility at ward level. Adherence to the European Working Time Directive and the abolition of the ‘firm’ system has resulted in a lack of communication and a diminution of personal responsibility for care of the individual patient. Perhaps the most dominant feature of this period has been the continual and

stifling interference at government level. The curious belief that the original principles of the NHS, as proposed by the Beveridge Report and put into place by Aneurin Bevan in the Labour government after the Second World War were inviolable, has resulted in resistance to any change or reorganisation by political considerations only. The Department of Health has become a monolithic organisation principally devoted to its own survival. The role of the doctor, and particularly that of the consultant, has been eroded to a level where we are looked upon as technicians, answerable to the bureaucracy, yet a ready target for blame and criticism. Much of the fault for this lies within our profession since we have simply refused to stand up to bullying and allowed the management ethos to overcome our responsibilities to our patients. I am pessimistic as to future progress and feel that I have been fortunate to work in happier times. The practice of orthopaedics has many aspects which may be enjoyed. Interest in the management of injuries sustained in sport is likely to produce requests to look after teams on a more formal basis. I became the medical advisor to the English and Irish Basketball Association and accompanied t he E nglish and Gre at B rit ain te ams around the world for some twenty years. This position carried membership of the medical committee of the British Olympic Association which gave an interesting view of medical politics at that level. My greatest pleasure, however, was to join, and eventually organise, the medical team

who looked after players and associated personnel for the MCC at Lords. This post also involved advice to the former Test and County Cricket Board, and later the early days of the English and Welsh Board. I was able to attend all the major matches at Lords in this capacity for some 30 years, giving me considerable insight into the game which had always been a major interest. During my training I was fortunate to work for Harold Jackson Burrows and later John Crawford Adams, stalwarts of what was then known as The Journal of Bone & Joint Surgery (British Volume) from its earliest days. They stimulated my interest in the Journal and the production of sound writing. At the request of Lester Lowe I began to rewrite papers for International Orthopaedics and, after his sad death, eventually became Chairman of its Editorial Board. I was first employed to rewrite papers for the JBJS (Br) in 1978 and eventually progressed to become the Editor and then the Editor Emeritus. The Journal has always been a major interest to me and it has been a great pleasure and privilege to work for it, and represent it on so many occasions. The practice of Orthopaedic Surgery has given me immense satisfaction and a very enjoyable life. In spite of the current political problems it will remain a rewarding and entertaining profession. A uthor

details

F.T. Horan

Former Editor, JBJS (Br) frank.horan@btinternet.com

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Consensus report

Innovations in knee surgery: the London Knee Meeting 2012 he London Knee Meeting, held at the Queen Elizabeth II Conference Centre, Westminster, in October 2012, involved a faculty of 23 leading international orthopaedic surgeons and over 400 delegates, sharing recent evidence, expert opinions and future developments in knee surgery. This article reports the key messages from this meeting and provides an overview of current thinking in knee surgery.

SPORTS INJURIES OF THE KNEE â&#x20AC;&#x201C; C O M M O N P R E S E N TAT I O N S A N D MODERN MANAGEMENT

Anterior cruciate ligament (ACL) reconstruction The number of separate bundles present in the normal ACL is controversial and are reported as between one and ten.1-3 Biomechanical studies on cadaveric specimens and finite element analysis have shown that the greater the number, the stronger the ligament and the better the control of rotation.4-6 Consequently, recent efforts have focused on determining the effect of the number of bundles on outcomes after ACL reconstruction.7,8 It is currently thought that, although biomechanically sound, more bundles only translate into better outcomes in surgeons with a high case-load of ACL reconstructions because of the greater technical complexity of the procedure.5,9 In a novel and informative presentation, Johan Bellemans described the importance of extra-articular structures to the stability of the knee joint, particularly the anterolateral ligament and its role in controlling tibial rotation.10 It was therefore suggested that this structure should be repaired at the same time as the ACL to provide greater rotational stability and reduce load across the graft sites. As more children take part in sporting activities, ACL reconstruction in skeletally immature patients is becoming more common and it is generally advised that in symptomatic patients treatment should not rely on bracing alone. 12,13 Most reports now advocate intraphyseal reconstruction, similar to the techniques used in adults. The effects on growth are

relatively small provided that measures such as slow drilling are used to prevent thermal injury to the physis plate.13,14 Postero-lateral corner (PLC) injuries Grade III PLC injuries are associated with rupture of one or both cruciate ligaments (ACL and PCL). 15,16 Therefore, where there is an acute cruciate ligament injury, the continuity of the postero-lateral structures should be assessed by a combination of clinical examination, MRI and arthroscopy.15-17 Lack of stability of the PLC structures has been associated with an increased rate of failure in cruciate ligament reconstruction and may be due to increased forces across the graft sites.18,19 Furthermore, untreated sprains greater than grade II give rise to a higher incidence of post-traumatic osteoarthritis.20,21 The recommendation at the meeting was to repair the PLC at the time of cruciate ligament reconstruction. Patellar dislocation: an update Acute dislocation of the patella is more commonly seen in young, active patients: height and weight are significant risk factors. It is associated with rupture of the medial patellofemoral ligament (MPFL) and medial retinaculum.22 It is debatable whether to treat first dislocations conservatively or to reconstruct the MPFL immediately.23 At present this treatment is reserved for recurrent dislocation and for those with an anatomical predisposition to instability. The role of MRI is crucial in diagnosis and in the identification of injury to the MPFL as well as the presence of osteochondral fragments which would require surgery.23 B I O LO G I C A L I NT E RV E NT I O N S / RECONSTRUCTION

Biological reconstruction Although microfracture continues to be the most common therapeutic technique for cartilage repair, the formation of fibrocartilage with a lower hyaline content than normal cartilage results in decreased durability, with functional outcomes deteriorating by two to

R. F. Kallala M. S. Ibrahim F. S. Haddad

five years after surgery.24 Conversely, the future for autologous chondrocyte implantation (ACI) looks promising with reports showing results that are equivalent to and in some cases superior to microfracture.25,26 The ultimate goal in the treatment of defects of articular cartilage is the regeneration of hyaline cartilage which completely integrates with the surrounding cartilage and bone, thereby restoring normal knee function. Several techniques are now in use which aim to achieve this goal. The use of scaffolds is rapidly evolving and involves filling the defect with a cellular or acellular matrix. New therapies for cartilage repair broadly fall into two categories: acellular scaffold systems (e.g. MaioRegen; JRI Orthopaedics Ltd, Sheffield, UK) and cell-based treatments (e.g. NeoCart; Histogenics Corp, Massachusetts, USA). The former tend to be single-stage procedures and are implanted to harness and augment the host response to injury. The latter involve a twostage procedure, in which chondrocytes are harvested and seeded onto a collagen scaffold. This encourages the production of hyaline-like structures in vitro that are then implanted back into the site of injury in a second procedure. This technique has been shown to be better than microfracture at two years follow-up.27 An algorithm for treating these articular chondral defects was proposed at the meeting and is summarised in Figure 1 (courtesy of Sam Oussedik, Consultant Orthopaedic Surgeon, University College Hospital, London). Treatment of Osteochondritis Dissecans (OCD) OCD occurs in the knee joints of younger patients and mostly affects the medial femoral condyle. Despite the publication of guidance on the treatment of OCD by the American Association of Orthopaedic Surgeons (AAOS), there is no clear consensus on methods of treatment. 28 However, what is clear is that displaced or unstable lesions require operative treatment, the options for which have included mosaicplasty, ACI, MACI or microfracture. A relatively new option is MaioRegen Scaffold â&#x2013;ş

BJJ News | I ssue 1 | O ctober 2013

(JRI Orthopaedics Ltd).29 This scaffold consists of three layers; a superficial layer of 100% deantigenated type 1 equine collagen, a middle layer of 60% collagen and 40% magnesium enriched hydroxyapatite (Mg-HA) and a lower layer of 40% collagen and 60% Mg-HA. The scaffold induces adhesion and differentiation of progenitor cells, which in turn synthesise bone and cartilage matrix according to the mineral gradient found in each layer. Research begun at the Rizzoli Institute has indicated that OCD in particular does better with the use of this scaffold construct.29 As a result of this promising research, an on-going prospective study has been set up at Ghent University by Peter Verdonk and his team. Meniscal repair and replacement Because of the increased risk of osteoarthritis after meniscectomy, current opinion is shifting towards repair rather than excision. 30 The outcome after repair is dependent on the orientation and location of the tear, duration of injury and age of the patient. 31 There is also a lower risk of recurrence when repair is undertaken within two weeks of injury.32 Large defects can either be replaced with allograft (88% success rate at seven-year follow up) or enhanced using synthetic materials such as scaffolds for meniscal regeneration. Although needing longer follow-up, meniscal scaffolds are a further option.33,34 These new modalities are increasingly used in young patients to avoid the onset of OA and in some cases, prevent it entirely. Other biological solutions such as fibrin clots can be placed within meniscal tears, thereby localising cells and growth factors at the site of injury which in turn act as chemotactic and biological scaffolds. Platelet-rich plasma (PRP) can also be used as an endogenous s o u rc e o f g row t h f a c to r s , p ro m ot i n g chemotaxis, angiogenesis, cell differentiation and extracellular matrix production.31 E A R LY I N T E R V E N T I O N F O R O ST E OA RT H R I T I S

Osteotomy Osteotomy around the knee still provides a useful alternative to replacement in the management of OA by allowing for correction of deformity while sparing the joint surface and delaying the need for TKR.35-37 Distal femoral varus osteotomy for valgus knee deformity should be considered in younger, higher demand patients with lateral compartment disease for whom TKR is not an option. Recent reports of long-term followup studies have concluded that osteotomy

results in improved function and pain relief comparable with partial knee replacement, but patient selection is paramount.38-40 Dr Peter Brooks presented the experience in Toronto, where a medial closing wedge osteotomy of the distal femur is used for correction of valgus deformity. This technique uses an 90° AO medial plate which permits secure fixation, dynamic compression and early mobilisation, and avoids the need for intra-operative measurements. A medial subvastus approach is used and a guide wire placed parallel to the joint line under image intensifier guidance. With the guide pin parallel to the joint line, the blade can be aligned

Articular chondral defect Favourable knee alignment?

Yes

Consider osteotomy

Lesion < 3 cm?

Microfracture

Failed microfracture? Lesion > 3 cm

Fig. 1

MACI

Proposed algorithm for articular chondral repair.

parallel to the femoral condyles of the knee and the plate fixed onto the shaft, giving a close to 0° alignment. In some centres instead of plate and screw fixation, osteotomies of the knee are managed with the aid of Taylor Spatial Frames (Smith & Nephew Ltd, London, UK) to better control position and the formation of new bone. Partial knee replacement The role of MRI before unicompartmental knee replacement (UKR) remains uncertain and recent reports indicate that arthroscopy is more sensitive in determining a patient’s suitability for UKR.41-43 Presenting unpublished data, Keith Berend found that an abnormal pre-operative MRI scan did not correlate with failure of UKR. This study looked at the pre-operative MRIs of 45 patients who had undergone UKR. Of these, 12 knees were reported as normal and 33 as showing degenerative changes in the lateral and/or patellofemoral joint and/or cruciate ligaments. There was no difference reported between groups in rates of failure or clinical and functional knee scores.

Although associated with higher revision rates in registries, partial knee replacement has a lower post-operative morbidity, faster recovery and similar patient satisfaction to TKR, with survivorship now reaching ten years.44,45 Indeed based on UK joint registry data, UKR now provides better functional outcomes than TKR for single compartment disease.46 It is therefore no surprise that the number of UKRs performed in the UK and internationally continues to rise. The indications and relative contraindications for fixed-bearing UKR are well known but do not appear to apply to mobilebearing UKR. A study from Oxford led by Chris Dodd compared outcomes in patients with and without contraindications to UKR and found that there was no difference in outcome or revision rates. Although performed in a high-volume centre by experienced surgeons, these results raise questions about the strength of the known contraindications and suggest that rates are more surgeon-dependent, with lower volume centres experiencing higher revision rates. Revision rates for UKR are three times those of TKR across all joint registries.47 The accepted indications for the revision of a UKR are aseptic loosening, progressive OA, infection and excessive wear. 47,48 In an unpublished multicentre analysis from the US by Berend et al (Joint Implant Surgeons, Inc., Ohio), 40% to 50% of revisions for UKR were due to aseptic loosening. They found that UKR was more likely to be revised on average a year and a half earlier and have lower rates of revision for infection than TKR. These data suggest either that aseptic loosening is being used as an indication for revision for unexplained persistent pain, or there is a bias towards early revision for pain after UKR compared with TKR (personal communication). An alternative view is that surgeons are less willing to revise a TKR than a UKR. In UKR, all-polyethylene tibial components are shown to have a higher rate of failure than metal-backed trays.49-51 However, recent unpublished data by Professor Fabio Catani of the Rizzoli Institute show that failure relates more to surgeon experience and prosthesis alignment than type of tibial component used. Patellofemoral arthroplasty: current and future practice Trochlear replacement is performed mostly for young, high-demand patients with isolated patellofemoral disease.52 Due to mal-tracking of the patella, these patients tend to be highly symptomatic and therefore present early. Excellent results are possible with patellofemoral

BJJ News

re-surfacing. However, unpublished research at Southampton about the biomechanics of the patellofemoral joint has shown that during knee flexion most of the force is distributed across the highly innervated soft tissues of the extensor mechanism rather than through the patellofemoral joint. As a result, it is the soft tissues around the patella that determine failure, not deficiency of the lateral femoral condyle. Third-generation trochlear implants have adopted a lower profile, equivalent to the width of the trochlear groove, to avoid lateral impingement of soft tissues that was seen in second-generation implants. It was stated that future patellofemoral surgery may involve patella aligned, soft-tissue sensitive implants. E N H A N C E D R E C OV E RY A F T E R K N E E R E P L A C E M E N T.

The increasing number of patients who undergo TKR, combined with the rapidly growing repertoire of surgical techniques and inter ventions, has put considerable pressure on surgeons and other healthcare professionals to produce excellent results with early functional recovery and a short hospital stay. The current economic climate has further restricted healthcare budgets necessitating brief hospitalisation while minimising costs. Local infiltration anaesthesia (LIA), developed by Kohan and Kerr in Australia, is a useful tool in the concept of fast-track surgery, which has allowed patients to mobilise the same day and be discharged with a lower requirement for post-operative analgesia.53,54 However, 12 to 24 hours after LIA a phenomenon of ‘rebound pain’ has been observed and, as a result, there was a call for the use of analgesic skin patches to provide longer-term analgesia. When compared with continuous femoral nerve block, LIA significantly reduced opioid consumption after TKR and reduced pain during physiotherapy.55 Pre-operative patient and family preparation is also important in improving patient outcome. Pre-operative education was found to reduce the length of stay, post-operative medication and post-operative anxiety after knee replacement.56 Conversely, the pre-operative use of walking aids, peri-operative haemoglobin concentration, failure to mobilise early and post-operative complications (including blood transfusion) are the most significant factors associated with prolonged hospital stay in patients over 75 years old.57

I N N O V AT I O N S I N K N E E

A uthor

REPLACEMENT

Although established in joint replacement, navigation systems are now being used in other areas of knee surger y. In ACL reconstruction, navigation has been used to achieve better anatomical tunnel placement and it has also been shown to improve the accuracy of osteotomy around the knee compared with conventional methods.13,58,59 Patient-specific implant technology is beginning to gain momentum. Research at Imperial College, London, is leading the way by using high-resolution CT scanning and 3D printing technology to create highly specific prostheses for use in degenerative conditions such as OA, but also when larger resections are required, as in malignancy. There has been a tendency in recent years not to resurface the patella at the time of primary knee replacement. 60 However, current evidence shows a substant ially higher incidence of anterior knee pain and re-operation rate if the patella is not re s u r f a c e d p r i m a r i l y. 6 1 I n t ra - o p e ra t i ve patellar margin cautery has also been shown to improve outcomes by reducing anterior knee pain. 62 Furthermore, patella-friendly designs with improved patellofemoral tracking and lower revision rates have been found to reduce the rate of anterior knee pain to 3%. The faculty supported resurfacing the patella in selected cases only, recommending resurfacing for Outerbridge Grade IV patellae, but not Grades I, II, and III. 63 Furthermore, there was a call to establish a patellofemoral validation score as an aid to future research. CONCLUSION

The past decade has seen great advances in knee surgery. Sports-related injuries and their management are generating growth in new areas of surgical treatment and in turn creating fertile ground for further research. Knee replacement, whether unicompartmental, bicondylar or total is evolving and, as a result of better understanding of knee biomechanics, better aligned prostheses are being implanted. Enhanced recovery from knee surgery is of particular interest in today’s economic climate. The coming years will witness continued growth in the fields of biological stimulation and bioengineering in order to further improve patient outcomes.

details

R. F. Kallala M. S. Ibrahim F. S. Haddad

University College Hospital London rami.kallala@gmail.com

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Clin

Orthop

Relat

Res

Active Members

N. Rossiter ■■ ■■

The Orthopaedic Trauma Society

■■ ■■

Along with a Royal birth, a new society has recently entered the scene. The Orthopaedic Trauma Society was launched at this year ’s Edinburgh Trauma Symposium and will run sessions at this year ’s BOA Congress, including an instructional course “Boot Camp”. Its first proper meeting will be at The Royal College of Surgeons on 6 & 7 March 2014 (details to be announced). This has been contemplated for a number of years by a group of like-minded surgeons from the British Isles with a primary interest in orthopaedic trauma. It has grown from a desire to have a society that fully and formally represents the subspecialty of orthopaedic trauma within the British Isles, and will be:

■■

Non-profit making

■■

A focus for orthopaedic trauma research in the British Isles

■■

A focus for orthopaedic trauma education and coordination in the British Isles

■■

A focus for orthopaedic trauma policies in the British Isles including injury prevention

■■

The organiser of scientific meetings on orthopaedic trauma in the British Isles

■■

A focus for orthopaedic trauma training in the British Isles

■■

Advance the practice of excellence in orthopaedic trauma

PRESENT OFFICERS: EXECUTIVE: President President elect Treasurer Secretary Education

Nigel Rossiter Bob Handley (Past President) Andy Gray Charlotte Lewis Mike Kelly

■■ ■■ ■■

Have applied for membership Have been nominated by two other active members Have been and/or are involved in the practice of orthopaedic trauma, research, publication and/or education Are ratified at a General Meeting by the membership Are eligible to vote at meetings Will pay a lower membership fee than active members Are ineligible to act as officers of the Society

Emeritus Members

A forum for orthopaedic trauma surgery in the British Isles

More details can be found our website:

Associate Members

■■ ■■ ■■ ■■

■■

It is envisaged that membership will be open to anyone, surgeon or otherwise, on application – details of which will follow with a website. There will be different categories of membership:

■■ ■■

Have applied for membership Are active practitioners at substantive consultant status, or equivalent Have been nominated by two other active members Have a proven track record in orthopaedic trauma practice, research, publication and/or education Are ratified at a General Meeting by the membership Are eligible to vote at meetings and serve as officers

■■ ■■ ■■

Previous Active Members who have retired from active practice who wish to remain members and are ratified by the membership at a General Meeting Are eligible to vote at meetings and serve as officers Will not be required to pay a membership fee Will be required to pay attendance fees at events

Honorary Members ■■

■■ ■■ ■■

Anyone nominated by the membership to the committee prior to a General Meeting and deemed to merit honorary membership Are ineligible to vote or serve as officers Will not be required to pay a membership fee Will be required to pay attendance fees at events

The society will be affiliated to the British Orthopaedic Association and may also affiliate to other societies.

www.orthopaedictrauma.org.uk COMMITTEE: Research Fellowships Liaison Membership Meetings PR/Website

Matt Costa & Ben Ollivere Daren Forward & Mark Jackson Bob Handley David Noyes Tim White Nick Hancock BOA Trauma Rep Tim Chesser (+ OTS President)

BJJ News | I ssue 1 | O ctober 2013

Notes from the road

P. E. Beaulé

International Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip June 2013, Quebec City, Quebec, Canada n June 2013, the 10th anniversary meeting of the International Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip meeting was held in Quebec City, which had also been the location of the first meeting in 2001. We were once again very fortunate to have an international faculty from France, Great Britain and Switzerland, as well as the United States and Canada, thereby bringing together the Old and New World within the fortified walls of Quebec City (Fig. 1). Over the years, the main purpose of the meeting has been to highlight controversial and relevant clinical issues in the treatment of the patient with pre-arthritic hip disease as well as those with advanced arthritis. Although stemmed total hip replacement with metal on highly cross-linked polyethylene remains the gold standard, it is clear from this meeting that patients benefit from other less invasive and bonepreserving procedures. When considering joint preservation, femoroacetabular impingement (FAI) remains the leading risk factor for early damage to the articular cartilage and arthritis of the hip. In gaining a better understanding of FAI, the role of 3D imaging and finite element modelling in defining the abnormal anatomy and planning the appropriate operation are playing a key role and expanding rapidly. Based on findings presented at the meeting, it is becoming clear that the pathomechanics of pincer and cam deformity are separate entities, cases needing combined treatment being in the minority. Also evolving are techniques of labral re-fixation and reconstruction. Because of the speed with which some of these techniques are being integrated into clinical practice, great care must be taken to minimise the risks of iatrogenic damage. Although somewhat eclipsed by the explosion of hip arthroscopy, the technique of surgical dislocation both in the management of acute slipped capital femoral epiphysis and in complex deformities, such as Legg-Calvé-Perthes disease and protrusio, remains essential. Periacetabular osteotomy (PAO) remains the gold standard for the treatment of hip dysplasia but adjunctive treatments such as hip arthroscopy to treat associated labral pathology are being explored: the presence of mechanical symptoms are probably the main indication for combined hip arthroscopy and PAO. Evolving techniques such as plateletenriched plasma injections, hip arthroscopy without the use of a traction table, capsular management after capsulotomy and

Fig. 1 The international faculty

capsulorrhaphy generated a significant amount of interest but require more investigation. Finally, extra-articular impingement and the snapping hip clearly involve complex combined deformities which include those of soft tissues, anomalies of femoral torsion and sub-spine impingement. As far as metal-on-metal hip resurfacing is concerned, the long-term follow-up both in registry studies and randomised clinical trials are showing this to be a viable option for young active male patients with good bone stock. Only a handful of devices are now used for hip resurfacing: cementless fixation on the femoral side seems to encourage bone remodelling. The monitoring of metal-on-metal implants remains a clinical challenge with the use of metal ion levels still unclear, leaving the clinician to rely on ultrasound imaging as the key screening tool. On the other hand, large head metal-on-metal primary total hip replacement is clearly no longer indicated because of the fretting/corrosive wear at the taper. This leaves the surgeon with a dilemma when revising the failed resurfacing: conversion to a large head metal-on-metal bearing or revision of the acetabulum component to a ceramic on polyethylene bearing. This problem led on to discussion of the role of dual-mobility bearings in total hip replacement. Some centres have started to use these for failed hip resurfacing when the acetabular component is well fixed. Although the role of dual mobility liners in the treatment of recurrent dislocation and in high-risk patients for instability after primary hip replacement is a proven option, stern warnings were issued by several of our faculty who have already seen cases of excessive wear within one year of implantation of a dual-mobility bearing into a ►

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resurfacing acetabular component. This results from the incompatible design of the resurfacing shell of less than a hemisphere with the dual-mobility acetabular component. As regards new technology, navigation techniques are getting more sophisticated and now actually guide the reaming and preparation of the bony bed of the acetabulum. Short stems are here to stay but it is unclear if they provide any true clinical benefit. Finally in terms of surgical approach, the anterior approach remains an attractive technique with very good clinical

results as well as allowing the optimal management of leg length in reconstructive cases because of the supine position of the patient and the ease of image intensification at the time of surgery. A uthor

details

P. E. Beaulé

Ottawa Hospital General Campus, Canada pbeaule@ottawahospital.on.ca

A. Seth Greenwald

Notes from the road

Current Concepts in Joint Replacement® Spring Meeting May 2013, Las Vegas, Nevada, USA he Current Concepts in Joint Replacement® (CCJR) meetings began 30 years ago and have evolved into a unique forum for orthopaedic surgical education particular to joint arthroplasty. They attract large international audiences and provide an orthopaedic learning continuum for the practitioner through the real-time didactic of the classroom, which is reinforced through the provision of enduring meeting m at e r i al s . The me e t ing s t he m se lve s e m ploy le ar ning methodologies inclusive of paper presentations, debate, surgical techniques and discussions focusing on challenging cases where arthroplasty is an advocated solution as well as faculty peerreview discussion of papers presented at recent international meetings. In its 14th year, the CCJR – Spring meeting is recognised worldwide as a premier continuing medical education event focused on hip, knee and shoulder arthroplasty. The course was open to orthopaedic surgeons, fellows, residents, nurses and members of the orthopaedic and allied health industries with the following learning objectives:

■■ Appraise evolving surgical techniques and implant technologies through didactic and interactive live presentation as well as evaluate early and longterm clinical outcomes. ■■ Identify problems and concerns relevant to hip, knee, and shoulder arthroplasty including polyethylene wear, metal-metal articulations, inter-component failure, peri-prosthetic fracture, as well as short- and long-term tissue response. ■■ Discuss optimal clinical application of current and evolving fixation techniques in primary and revision procedures including cement, hydroxyapatite, porous coating, press fit, impaction grafting, and evolving porous metal technologies.

■■ Identify solutions to difficult hip, knee, and shoulder reconstruction problems. ■■ Describe contemporary solutions to problems of bone loss in hip, knee, and shoulder reconstruction. The meeting was held at the ARIA at CityCenter in Las Vegas, Nevada, USA. A world-renowned faculty of 55 thought leaders educated 625 medical professionals, half of whom were from 50 countries outside the United States. The total meeting attendance was 930. There were 33 technical exhibitors and included orthopaedic device manufacturers, publishers and non-profit organisations. The internationality of the meeting is growing and this can be measured directly against a number of foreign-based companies that exhibited. These included CeramTec (Germany), Medical Compression Systems (Israel), SERF Dedienne Sante (France) and United Orthopedic Corporation (Taiwan). Beyond the Live Meeting and in addition to a comprehensive abstract book, course proceedings are recorded on audio mp3 with the live surgeries placed on a DVD; all of which are distributed to every course participant. The meeting, in its entirety, is placed on www.CCJR.com for continual reference to attendees with selected papers also being available through the CCJR App. All provide exceptional enduring materials and define the learning continuum that CCJR represents. Further information and registration for the upcoming 30th Annual CCJR – Winter meeting, which will occur in Orlando, Florida, USA , 11 – 14 December 2013, can be found at www.CCJR.com. A uthor D etails

A. Seth Greenwald

ourse Director, Current Concepts Institute, Ohio, USA C info@CCJR.com

BJJ News | I ssue 1 | O ctober 2013

P. C. Ho C. Wong

Notes from the road

Evolution of The Hong Kong International Wrist Arthroscopy Workshop and Seminar

Fig. 1 Dr Ho demonstrating at the f irst workshop in 1997

t is 16 years since the launch of the Hong Kong International Wrist Ar throscopy Workshop and Seminar. Founded on 14 November 1997 by Professor LK Hung and Dr PC Ho, who aspired to create a platform to share and spread the experience and virtues of wrist arthroscopy, it has been an annual event, except for 2003 when there was an outbreak of SARS (Severe Acute Respiratory Syndrome) in Hong Kong. The course has evolved from a short demonstration in a half-day programme of wrist arthroscopy to a three-day course which includes one day of seminars and clinical workshops and two days of live surgical demonstrations with hands-on basic and advanced fresh cadaveric workshops. The venue has also evolved from a small seminar room in a ward to two advanced training facilities in our hospital where the course is held concurrently. One is the OLC (Orthopaedic Learning Center), a state-of-theart bioskills laboratory with sophisticated audio-visual equipment which we have used since 2000. The other is the MISC (Minimal Invasive Surgical Center) located on an upper floor of OLC.

The course has matured as problems such as drainage of the irrigation fluid and mounting of the cadaveric limbs, were resolved. In 1997, we only had one demonstration table and a simple container in which to collect fluid. Later, primitive basins with traction stands and outlets for fluid were designed which allowed us to have more work stations. In 2004, we created newer basins with drainage filters and better drainage. A further important breakthrough came in 2009 with the renovation of the OLC, where there were built-in set-ups and specialised equipment

Fig. 2 Workshop in action

for arthroscopic workshops. Nowadays, we can manage 13 customised work stations in the OLC and eight mobile stations in the MISC. In the early days, we obtained cadaveric limbs from the Chinese University of Hong Kong after they had been used to teach anatomy to their medical students. Because they were embalmed in formalin, a good ventilation system was essential for a workshop that ran for the whole day. We discovered that a thorough manipulation of the wrist joint and sectioning of the tight tendons were critical preparatory steps to ensure easy insertion of the arthroscope and to minimise potential damage to its lens. Since 2010, we have purchased fresh-frozen cadavers from overseas which has significantly improved the quality of the specimens. We have also been fortunate in our relationships with most of the Hong Kong companies which make arthroscopic equipment and have sponsored the use of their instruments. The course was initially aimed at surgeons from mainland China. However, in February 2008, the 7th APFSSH (Asian Pacific Federation of Societies for Surgery of the Hand) Congress was held in Hong Kong and became a catalyst for the course to be transformed into an international event: we were able to gather nine experts from all over the world to teach on the course before the Congress. Since then, we have received tremendous worldwide support from many leaders and experts on an annual basis. So far, 22 different overseas experts have attended as our international panel, and 30 from the public and private sectors

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It is an ideal place to learn directly from the masters and share their experience in a friendly and intimate manner

A uthor

details

P. C. Ho Consultant and Head of Division of Hand and Microsurgery C. Wong Consultant Hand Surgeon Prince of Wales Hospital, Sha Tin, New Territories, Hong Kong pcho@ort.cuhk.edu.hk

Fig. 4 Par ticipants at the 2012 Hong Kong International Wrist Ar throscopy Workshop and Seminar Fig. 3 Customised workstation for cadaveric wrist ar throspcopy

form the local faculty. The course has attracted participants from many parts of the world. Since 2000, there have been more than 800 participants from 25 countries, of which Hong Kong accounted for 54%, China 12%, Japan 6.7%, Thailand 4.6%, Korea 3.6%, Singapore 2.5% and Europe & America 16.6%. The 2013 Hong Kong International Wrist Arthroscopy Workshop and Seminar will be held between the 16 th and 18th November. We are pleased to have invited a strong international faculty panel of 25 overseas and local experts to conduct the course. Its design is three-fold: 1 Clinical workshop on the management of chronic wrist pain, including hands-on training on examination of the wrist and the evaluation of clinical cases 2 A symposium on scaphoid fractures, nonunion and related wrist problems, highlighting the role of arthroscopy 3 Basic and advanced cadaveric wrist arthroscopy workshops. This year the new exciting element is a cadaveric workshop on total wrist replacement and percutaneous scaphoid fixation, conducted by world experts in the field. The basic workshop aims to help the inexperienced surgeon to acquire the fundamental skills and most popular techniques to start their practice in wrist arthroscopy. The advanced workshop provides hands-on experience of cutting-edge techniques in

different diseases and has stimulated many new ideas in this exciting branch of hand surgery. However, our wish for the course is not only technically orientated, but also to deliver the principles of arthroscopy in different clinical situations in the management of chronic wrist pain. A thorough understanding of wrist pathology, a well-conducted clinical assessment and a systematic analysis of conditions which cause chronic wrist pain are essential for a successful outcome. Our workshop centre is a joyful jungle, filled up with cadaveric limbs, drip stands and people in blue gowns. Everybody is busy with teaching and learning from early morning to late afternoon. It is an ideal place for those interested in arthroscopic surgery of the wrist to learn directly from the masters and to share their experience of wrist problems in a friendly and intimate manner. There is also a rich social programme to enjoy, a very warm and entertaining welcoming banquet and a faculty dinner with authentic Chinese food. Maybe you are one of our participants who has attended the course on many occasions. Perhaps you are so haunted by the big questions of wrist problems and arthroscopy in your daily practice that you would like to come and receive wise advice and instruction. We warmly welcome you to experience, explore and enjoy. Please feel free to download the application forms and gain more information from our website at www.olc-cuhk.org. You are also welcome to contact our programme secretary, Ms Natalie Chin at olc@ort.cuhk.edu.hk for all enquiries.

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The capsular arthroplasty: an effective but abandoned procedure for young patients with DDH.

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2013 Congress coming soon for all BOA members

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Trainee corner

J. Palan

BOTA Conference 2013 British Orthopaedic Trainees Association Annual General Meeting

his year, the annual BOTA educational weekend and Annual General Meeting were held between 31 May and 2 June at Carden Park near Chester. The educational weekend is the highlight of the BOTA calendar and attracts more than 150 delegates to a mixture of lectures and hands-on practical workshops. The standard of the lectures has always been critical to the success of the weekend and this year proved no exception. There were outstanding presentations on a variety of topics including ankle conditions for the FRCS (Professor Roger Atkins, Bristol), hip impingement (Mr Johan Witt, UCL London), shoulder conditions ( P r o f e s s o r S i m o n Fr o s t i c k , Liverpool), the athlete’s knee (Mr Andrew Barnett, Oswestry), pelvic fractures (Mr Mez Acharya, Bristol), major trauma (Professor Iain Pallister, Swansea) and paediatric orthopaedics (Miss Karen Daly,

Fig. 1 Mr Stephen Bale Trainer of the Year, 2013

St George’s London). There were also presentations about nonclinical aspects of orthopaedic practice by Mr Ian McDermott, on life in independent practice, talks by Mr Ricky Villar (Former Editor-in-Chief, BJJ) on how to get published and a presentation by Mr Martyn Porter (President, BOA) on the future challenges facing trauma and orthopaedics. The combination of clinical and nonclinical presentations provided a broad educational platform for trainees. This was supplemented by a series of hands-on practical workshops, with the generous support and help from a number of key industry partners, who provided both the technical support and equipment to allow cementing workshops, Sawbones stat ions with intramedullar y nailing, Exeter Trauma Stem hemiarthroplasty, periprosthetic fracture plate fixation and fixation of fractures of the distal radius. The weekend also provides the opportunity for trainees to recognise outstanding trainers from across the UK: the BOTA Trainer of the Year presentation is made during the formal blacktie dinner. This year, there were almost 30 submissions from the UK Deaneries, including Scotland, Wales and Northern Ireland, from which Mr Stephen Bale (Wrightington), Mr Sashin Ahuja (Cardiff) and Mr Tim Green (Leicester) were voted the top three trainers. They were invited to attend the presentation ceremony with their respective partners. The winner and Trainer of the Year 2013 was Mr Stephen Bale who highlights all the qualities of an exceptional trainer. It is

May / June 2013 Carden Park, Cheshire, United Kingdom

very reassuring to see so many being nominated for this award and emphasises the importance of recognising those who are delivering the highest quality surgical training in the UK. Over the last few years, the BOTA educational weekend and Annual General Meeting have also provided the opportunity to host the Training Programme Directors (TPD) Forum which allows TPDs and trainees to discuss issues of training. The forum was also attended this year by Mr Mike Kimmons (Chief Executive of the BOA), Mr Mark Goodwin (Chairman of the SAC Trauma and Orthopaedics) and Mr Ian Eardley (Chairman of the JCST). The main issues of concern amongst trainees were the difficulty in gaining experience in certain types of operations such as first ray surgery (especially in Northern Ireland where podiatrists provide a foot and ankle service) and the fact that some operations, such as first ray surgery and carpal tunnel decompression were being undertaken in independent centres. Furthermore, concerns were raised about the implementation of the new requirements for trainees to obtain their CCT, in particular, the difficulties senior trainees were facing in achieving the required number of index procedures. It was acknowledged that the CCT requirements should be used with discretion when applied to trainees approaching their final ARCP review. This forum is an invaluable opportunity for all concerned to identify, debate and discuss the numerous challenges facing trainees and trainers in ensuring

This forum is an invaluable opportunity for all concerned to identify, debate and discuss the numerous challenges facing trainees and trainers

that surgical training and standards are maintained. The TPD forum provides real-time feedback to TPDs, the SAC, BOA and JCST from trainees and can very quickly highlight potential problems occurring in different regions across the UK. It was therefore a little disappointing that only three TPDs attended the forum and it is hoped that more will attend next year. In order to facilitate this, BOTA has received support from the BOA, the Chair of the SAC and Mr Paul Manning (Chair of the TPD forum) to encourage all TPDs to attend next year. The 2014 BOTA educational weekend and Annual General Meeting are once again being held at Carden Park (20‑22 June). I very much hope to see even more trainees attending and supporting this event. A uthor

details

J. Palan

British Orthopaedics Trainees Association (BOTA) jeya_palan@hotmail.com

BJJ News | I ssue 1 | O ctober 2013

Bridging the gap

Ganga Hospital: vision and mission he challenges of delivering healthcare in a country like India are enormous. Burdened with a population of 1.2 billion and with a government able to spare only 3% of its GDP for health (as in many other developing nations), its efforts are largely restricted to basic issues such as the control of infectious diseases, prevention of epidemics, mass immunisation and reducing the rates of maternal and infant mortality. Many aspects, even of primary care in specialised areas like bone and joint disease, are entirely borne by the private sector. More than 90% of all operations are paid for by the patient: this is usually is made possible only from life savings and support from close family. There is obviously an enormous gap between the need and the Government’s ability to fulfil that need. This is where doctors and private hospitals have an important and unique role to serve society. There is a particular need for the design of specific models which can make quality treatment available and affordable. It is fortunate that there are many successful and outstanding models in South India that have been able to deliver good healthcare at a fraction of the cost of operations in the West. Arvind Eye Hospitals for ophthalmology, Narayana Hrudalaya for cardiac care and Ganga Hospital for orthopaedics and plastic surgery are three outstanding examples of institutions that successfully practice this philosophy. Despite the low cost, the quality of care provided is really high, which is confirmed by the fact that these institutions are functioning as outstanding teaching and training institutions with clinical outcome measures comparable with the best in the world. Ganga Hospital was founded 35 years ago by Mrs S Kanagavalli and Dr J G Shanmuganathan, who had the intention of establishing a hospital that would provide every patient with the best treatment at affordable cost. The beginnings were humble with only 17 beds and two operating theatres and growth was slow in the first two decades. The hospital was converted into a specialty centre for orthopaedics and plastic surgery when their sons Dr S Rajasekaran

and Dr S Raja Sabapathy returned from their training in the UK in 1991. The establishment and development of a specialty centre was not easy but their relentless spirit, determination and hard work made the dream come true. The family preached integrity, ethics, professional and family values, which, by example imparted trust and confidence to a committed team and patients alike. Today, Ganga Hospital stands tall amongst medical institutions for its professional and academic excellence. Its inherent strength is a skilled and committed team united by the common goals of professional excellence and social service. With over 22 000 operations annually, made possible by 486 beds and 18 operating theatres, the hospital is the largest specialty centre for orthopaedics and plastic surgery in South Asia. The large volume has made it possible for the hospital to continuously acquire and adopt relevant and clinically useful cutting-edge technology. Throughout its growth, the unit has maintained its philosophy of reaching out to the poor and developing its ability to perform high quality surgery successfully at low cost. Around 30% of their operations are routinely done for the ‘Below Poverty Line’ sector of society where the total cost for a patient requiring interlocking nail surgery can be as low as US $500, a total knee replacement $1300 and major spinal surgery under $1900. The hospital also undertakes a large number of free operations under ‘Project SWASAM’ (Breath of Life) with donations and funds from numerous service organisations. The hospital is also well known for its clinical and basic science research publications and contributions and has been the recipient of numerous national and international awards. It has postgraduate training programmes in orthopaedics and plastic surgery and its numerous fellowships and training courses are fiercely competed for worldwide. In the last ten years more than 750 surgeons from 28 countries have had short and long-term training at the hospital. All this has been made possible because of the ‘Dream of the Founders’. To celebrate

S. Rajasekaran

the journey, an annual Founder’s Oration was established with the aim of inviting an eminent person whose success was achieved through hard work, honesty, enthusiasm and more importantly social commitment to deliver an oration every year. The presence and words of such an individual will inspire people to dream and create institutions of excellence for the benefit of society. The inaugural oration was delivered on 14 June 2013 by Dr Devi Shetty, Chairman, Narayana Group of Hospitals, Bangalore in the presence of Hon. Justice P Sathasivam, currently the Chief Justice of India. Dr Shetty was an outstanding choice as he epitomised Ganga Hospital’s vision and mission not only to be the best in patient care and surgical expertise but also to provide high quality treatment at affordable cost so that the expertise would be available to every citizen of

There is obviously an enormous gap between the need and the Government’s ability to fulfil that need the country. Dr Shetty and his team have performed 70 000 major heart operations, of which 15 000 were on children. He is passionate about making the expertise of his team affordable to the masses and has made open heart operations in infants possible for US $1400, with outcomes comparable with the best institutions in the world. He was the first to coin the phrase ‘Micro Health Insurance’ and has helped his state government to run the largest successful micro health insurance scheme in the world. He has won numerous national and international awards and we were indeed fortunate to have him to deliver the inaugural oration on ‘Affordable Health Care’. A uthor

details

S. Rajasekaran

Chairman, Dept. of Orthopaedic and Spine Surgery, Ganga Hospital, Coimbatore, India sr@gangahospital.com

BJJ News

Bridging the gap

Ganga Hospital Founder’s Lecture: Deciding a price tag for human life

Ganga Hospital, Coimbatore HE DAILY REALITY

Doctors treat the sick and have the noble task of healing diseases. But every doctor in India, during the course of treating the ill, also has the dubious job of “putting a price tag on human life”. Consider this grim but true scenario. A busy cardiac surgeon in India is examining a child with congenital heart disease. After examining the child, he explains to the parents that the child has a hole in the heart that needs an operation. Just like any other parent, the unfortunate parents are struck by awe, shock, despair and disbelief. They are awed not because their son would go under the knife but by the financial impact of the surgery. They have only one question; how much the operation would cost. The surgeon tells them that it is going to cost £1000. That is the price tag on the innocent child’s life. If the parents come up with £1000, they can have the child and if they do not, they are going to lose him. This is not a rare situation and it is what all the doctors in India do from morning to evening: put a price tag on human life. The root cause is that 80% of the national expenditure of healthcare in India is borne out of the pockets of individuals. Because the government spends only 1.1% of GDP on healthcare, 47% of the rural and 37% of the urban population borrow money or sell assets to pay medical bills. The consequences are disastrous.

Let’s take the example of heart operations. Indians are genetically three times more vulnerable to heart attack than Caucasians. In the author’s practice, it is not the young son bringing his old father for a heart operation; rather it is the old father bringing his young son for bypass grafting. India needs two million heart operations a year but unfortunately Indian cardiac surgeons perform only about 120 000 and the rest perish gradually over time. In the process, India is probably producing the largest number of young widows in the world. However, even with the backdrop of this gloomy picture, we are optimistic because India produces the largest number of doctors, nurses and technicians in the world and, outside the USA, has the largest number of USFDA drug manufacturing units. HOW DO WE CHANGE THINGS?

India does not need massive investment plans in healthcare. All we need are policy changes. Indian villages do not have medical care because in India this can legally be delivered only by a person with a title of MBBS. There are over 20 000 alternative medicine specialists who are graduating from the same medical universities and can assist MBBS doctors in delivering rural healthcare. Across the world, primary healthcare is generally provided by nurse practitioners and

D. Shetty

physician assistants along with the doctors. Unfortunately, in India, even a trained nurse who has worked in a critical care unit for 20 years is not legally allowed to give an injection or even prescribe a paracetamol tablet. This has to change. There is also no career progression for a nurse other than doing their MSc and pursuing an academic career. In terms of patient care, they cannot progress to become a nurse practitioner or a nurse anaesthetist or even prescribe a paracetamol tablet. Unless these major changes happen, it is only a matter of time before the nursing profession will be dead. For these major shifts to happen, India needs to address the current situation of the doctor being the sole custodian of healthcare. We have to empower other professionals to be involved in the process of healing. The Bureau of Labour statistics from USA shows that out of the 20 fastest growing occupations in the USA, 15 are in healthcare. Unfortunately, none of those 15 training programmes exists in India. Why can we not train village girls with a basic standard of education to assist at simple surgical operations thereby releasing nurses with a Bachelor of Science degree for more demanding duties? India has one of the highest maternal mortality rates in the world mainly because approximately 28 million babies are born every year. To conduct 28 million deliveries at least 100 000 gynaecologists are needed. Unfortunately, there are less than 40 000. Therefore, irrespective of the government’s intention to reduce maternal mortality by spending billions of dollars, this is not going to change unless more medical specialists are trained. There is an organisation called The College of Physicians & Surgeons, established 105 years ago, which is the first Indian Medical University to award postgraduate degrees but these, unfortunately, are recognised only in Maharashtra and Gujarat; the rest of the country, especially states with very high maternal and infant mortality rates, do not recognise them. Similarly, every year 150 000 new patients are diagnosed with chronic renal failure and require dialysis but 135 000 die without getting it. This is because there are very few positions to ►

BJJ News | I ssue 1 | O ctober 2013

Dr Devi Shetty receiving Founder’s Award from Justice Shri P Sathasivam (Chief Justice of India)

From left to right: Dr S Raja Sabapathy, Dr S Rajasekaran, Justice Sathasivam, Shri D R Kaarthikeyan (Former CBI Director of National Human Rights Commission), Dr Devi Shetty, Dr J G Shanmuganathan, Mrs K. Shanmuganathan

train nephrologists. To address the problem of medical specialists, a novel programme called Udayer Pathey has been launched in West Bengal. The intention is to train 2000 children from villages in West Bengal to become doctors and superspecialists. The requirement is that these children, when they are 13 years of age, should commit to becoming doctors. A scholarship of $5$10 per month is provided and they are mentored to get into medical colleges and assisted to get a bank loan. WHY HEALTHCARE IS IMPORTANT FOR THE WORLD

The economy of the 20th century was addressed by machines which eased human toil. The economy of the 21st century will be driven by the health sector which is the only industry that can create millions of jobs for extremely skilled, semi-skilled and unskilled people. In the last ten years, the world has seen unemployment grow and wealth accrue in the hands of the very few. One cannot have equitable growth and equity in society without job creation and the health sector is an excellent industry to fulfil this aim. The National Health Service (NHS) of the United Kingdom is one of the largest employers in the world and the economy of Britain today is still vibrant because of its job-creating capacity. The NHS is more than a healthcare provider for the country. It is the driver of the British economy, distributing over £5 billion in salaries every month to about 1.2 million households. On similar grounds, unless a developing country like India creates jobs for women from lower socio-economic classes, equitable growth cannot be achieved. Once a woman from a lower

socio-economic background is employed, she becomes empowered. She will discipline her children, who when they grow up, will build a stronger nation. The problem with healthcare across the world is that the governments believe that tax payers’ money can pay for it. This was only possible when the life expectancy was 65 years. Today people celebrate 95th and 100th birthdays. As more are going to live longer without working, who will pay the taxes? Technological innovations will also create new problems. The author has implanted several Left Ventricular Assist Devices (LVAD) when a donor heart was not available. These patients can lead normal, active lives beyond 60 years of age, recharging their artificial hearts in a village with a second hand diesel generator. So, as all this technology will add ten extra years of life, where again are the tax payers? Around ten years ago the author convinced the state government to launch a micro health insurance programme called Yeshasvini, to which 1.7 million farmers contributed 11 cents per month and the government agreed to become a reinsurer. After ten years, 444 460 members of this scheme had undergone a variety of operations and 66 504 members had cardiac surgery and intervention. All this was done with the power of Rs. 5/- i.e. 11 cents per month. This insurance pays only for the operations. Four hundred hospitals were linked across the state and the member has the option to choose any of these. EFFECTIVE LOW COST HEALTH MODELS

India has 850 million mobile phone subscribers who each spend Rs. 150/- per month. If only Rs. 20/- per month were deducted for health

insurance, we could cover most of our population. Our other problem is the high cost of government spending on building various hospitals. The author has collaborated successfully with one of India’s largest construction companies to build a 300- bed superspecialty hospital and equip it for $6 million and commission it in six months. There are 100 towns in India with populations of between half to one million where there is no superspecialty hospital. These low-cost model hospitals could be built in all these towns. Such simple but effective models have been on the cover page of The Wall Street Journal (25th November 2009) and, for the last seven years, these innovative concepts have been the first case study to be taught to the MBA students of Harvard Business School. The efficiency of these budget hospitals relies on effective financial management. Each day at noon, senior doctors and administrators get a text message on their mobile phones with the previous day’s revenue and expenses. Looking at the profit and loss account at the end of the month is like reading a postmortem report, whereas looking at the account on a daily basis is a diagnostic tool for remedial action. In developing countries, the author believes that the most expensive piece of medical equipment is the doctor’s pen. Just by prescribing CT or MRI, which may not change the course of the patient’s care and outcome, we end up losing thousands of dollars. ‘BE THE CHANGE YOU WISH TO SEE’ MAHATMA GANDHI

Charity is not measurable according to a scale. In order to promote such effective health care models, an organisation called The Association of Healthcare Providers (India), which represents over 4000 leading hospitals in the country, has been created. In support of these efforts, the state policy makers were sufficiently convinced to reduce the electricity tariff by 15%. To address the problem of heart patients across the country, Indira Gandhi National Open University has agreed to start a course called Diploma in Community Cardiology. When the government tried to add 5% service tax on healthcare, the author led a protest and convinced the government by a campaign called “It is not service tax, it is misery tax”. In less than two weeks, the government withdrew the service tax. This shows that the doctors with good intentions can change policy and make this world a better place in which to live. A uthor

details

D. Shetty

Chairman, Narayana Hrudayalaya Group of Hospitals, Bangalore, India devishetty@nhhospitals.org

BJJ News

Bridging the gap

Orthopaedics in an unequal world

M. Laurence

Michael Laurence reports on the main topic of the forthcoming SICOT meeting in Hyderabad

n t h e i r w i s h to o ve rc o m e worldwide inequalities, the central ethos of SICOT and World Orthopaedic Concern (WOC) is to concentrate on teaching and training, according to the timeless principle of ‘enablement being more effective than gifts’ (c.f. the example of teaching an individual to fish vs the giving of fish). Western society faces crises of capitalism. The very word “charity” has acquired something of an odour, particularly among those who see their own countrymen thrown out of work for economic reasons. This has been partly responsible for the shrinkage of donations. I am reminded of a criticism of the “Live Aid” campaign thirty years ago which aimed to relieve famine and save lives in the Horn of Africa. How could the farmers of East Africa compete commercially with “free food”? Result - agricultural bankruptcy. Lesson - gifts can disturb the balance within a community! Occasional incidents of dishonesty or misappropriation of donated funds have given support to right-wing politicians and the critics of philanthropy. The “simple” answer of benevolent donation is a very incomplete and uncertain solution. The real need, for expert training, is not expensive, nor is it in short supply. There has never been a time in which so many orthopaedic surgeons with huge experience have just retired. Many of these are frustrated by obligatory and uncomfortable idleness. Moreover they comprise that rare cohort that was trained 50 years ago, in the very conditions still prevalent in Low and Middle Income Countries (LMIC). The new young tyros from the ‘centres of excellence’ will not find it easy to follow without access to sophisticated modern tools.

nd yet it is more complicated than that. There is a difference between the conditions that prevail in an af fluent compared with an impoverished society and the way in which they are managed. The sheer numbers of patients do not allow the time to conduct the in-depth clinical evaluation required by modern (western) academic examinations. So the training for practice must differ in emphasis from that needed for academic scholarship. In the LMIC, diagnosis depends more upon the eyes, directed

I saw the results achieved by former and current British surgeons ... the difference they had made was quite stunning at the moving patient, than the hands. Beside speed, what is needed is a degree of sensitivity, compassion and realism, none of which is easily taught. They require the intimacy of an expert instructor who will have had the necessary lifetime to develop those skills. This disparity is at the heart of the difference between teaching and training. The acquisition of facts can be achieved through books, electronic media, lectures and demonstrations, but the practical aspects of surgical performance requires close personal collaboration with the trainer in the clinic, ward and operating theatre. There is a world of difference between watching a sporting performance and taking part. That is the value of apprenticeship. Skill develops in the course of supervised performance (with the rare exception of the remarkably gifted!).

any of the aids to education, common to the West, have transferred well to the LMIC, with some distinct improvements. One relates to the logbook kept by trainees to record the operations they have performed and the points learnt by each experience. I have persuaded many to include difficult cases not operated upon, with the reasons why, and the ease or otherwise of their management. The value of “bitter experience” in the acquisition of knowledge, does not have be your own! Gwyn Evans (retired from Oswestry) writes to recall his experience of many two-month visits to Assam and Malawi, during an eightyear period before and after he retired. He writes: “I saw the results achieved by former and current British surgeons who had gone to these places for lengthy full-time periods. The difference they had made was quite stunning. Hospitals had been set up, with outreach services into the more rural communities. Gradually, over years, their skills had been transferred to local graduates. A fantastic achievement.” It is a fundamental principle of WOC to encourage those who have or are about to retire from orthopaedic practice, to preserve their interest (and youth) by travelling, not so much to teach, as to train. To lecture, show slides, or demonstrate is not enough. Facts can be disseminated, but training requires “hands-on” guidance during each stage of an operation.

A uthor

details

M. Laurence

President of World Orthopaedic Concern

International This article is a shortened version of one previously published in the newsletter of WOC

laurence.mike@gmail.com

BJJ News | I ssue 1 | O ctober 2013

Fellowships

American-British-Canadian Travelling Fellowship 2013 n April 2013, seven orthopaedic surgeons from the United States and Canada arrived in London on an uncharacteristically sunny day to begin t he histor ic ABC fellowship tour of the United Kingdom and South Africa. The Canadians were Michelle Ghert, MD, FRCSC, an orthopaedic oncologist from McMaster University and Albert Yee, MD, FRCSC, a spine surgeon from the University of Toronto. The five US surgeons included Gregory Della Rocca, MD, PhD, a trauma specialist from the University of Missouri; Ranjan Gupta, MD, a brachial plexus/shoulder and ner ve surgeon from the University of California-Irvine; two sports medicine specialists, Matthew Provencher, MD from Massachusetts General/Harvard and Brian Wolf, MD from the

University of Iowa; and Jennifer Moriatis Wolf, MD, a hand surgeon from the University of Connecticut. Hosted by the British Orthopaedic Association and The Bone & Joint Journal, the fellows had the opportunity to visit nine sites in the United Kingdom (Table 1), and learned about the current issues affecting the hospitals and the national health care systems of each. Highlights included the first visit of ABC fellows to Cardiff University in 30 years as well as Professor Ashley Blom’s enlightening talk about the National Joint Registry for England and Wales (NJR) there; attending the Seddon Society at the Royal National Orthopaedic Hospital at Stanmore as well as a behind-the-scenes tour of the Tower of London; a weekend in

Oxford with presentations on the patient reported outcomes measures (PROMs) research being done there, followed by tours of Blenheim Palace and the Oxford campus; the amazing variety in the tumour conference a t t h e R o ya l O r t h o p a e d i c Hospital at Birmingham; a tour of the theatres and the Charnley Museum at Wrightington/Wigan/ Leigh; or thopaedic implant manufacturing tours and a visit to Chatsworth House in Sheffield; learning about the trauma legacy at Edinburgh as well as a wonderful home-cooked dinner at the home of Professor Hamish and Helen Simpson; discussing regional trauma and triage changes in Northumbria; and a visit to the Hunterian Museum in Glasgow followed by a dinner in formal Scottish dress. In addition, the fellows were

J. M. Wolf A. Yee B. Wolf M. Provencher R. Gupta M. Ghert G. J. Della Rocca

feted at the BOA dinner aboard the HMS Wellington in London. We visited many hospital sites, and learned about the many accomplishments and challenges in UK health care: how the NJR affects care and implant choices; surgeon outcome analysis and disclosure; and cooperative integrat ion of trauma care delivery. Finally, the fellows also spent an afternoon at The Bone & Joint Journal, learning about its new directions and initiatives from in-house editorial staff. The fellows travelled from London to Johannesburg, South Africa. We visited five South African cities and multiple sites within each: Johannesburg, Pretoria, Durban, Bloemfontein, and Cape Town (Table 2). We learned about the focus on trauma in orthopaedic care, as

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Orthopaedic Association Leadership 2013 ABC Tour Organisation BOA Martyn Porter, President; David Stanley, Secretary The Bone & Joint Journal Richard Villar, Former Editor

Un i te d Ki n gdo m: P r i mar y Ho sts f o r th e 2 0 1 3 A BC Exch an ge Fe l l owsh i p

SAOA Allen van Zyl, President

well as the challenges presented by human immunodeficiency virus (HIV) and tuberculosis. Highlights here included: live patient presentations at rounds in Pretoria; a visit to Baragwanath Hospital, the second largest in the southern hemisphere, near Johannesburg, as well as a visit to Soweto; touring the ar throscopy teaching facility in Durban; touring the medical school, with faculty ‘tips’ talks in Bloemfontein; and a University of Capetown/ Tyg e r b e rg c o m b i n e d f i n a l present at ion in Capetown, with a fellow hike up Table Mountain and some regional winery visits as well. Also, the fellows had the opportunity to visit the Pilanesburg game park and Thanda Nature Reserve, and experience the natural and unique beauty of South Africa.

A uthor

Table 1

he 2013 ABC Tour was a phenomenal experience for each of us. We each learned far more than we taught, and returned to North America with new friendships, collaborations, and future visits planned. The 2013 ABC fellows thank The Bone & Joint Journal, the BOA and SAOA for their incredible hospitality, as well as their support of this academic and cultural o p p o r t u n i t y. We a re ve r y a p p re c i a t i ve o f t h e m a ny individuals who helped plan this once-in-a-lifetime experience.

Site

P r i m ar y A BC Hos t ( s )

Cardiff

Stephen Jones Marcellino Maheson

London, ROH Stanmore

Timothy Briggs (ABC Fellow 1998)

Oxford

Duncan Whitwell (ABC Fellow 2012) Peter McLardy-Smith

Birmingham

Simon Carter (ABC Fellow 1996) Robert Grimer (ABC Fellow 1990)

Wrightington, Wigan and Leigh

Anil Gambhir Martyn Porter (ABC Fellow 1994)

Sheffield

David Stanley

Edinburgh

Leela Biant (ABC Fellow 2010) Hamish Simpson (ABC Fellow 1996)

Newcastle and Northumbria

Mike Reed (ABC Fellow 2012) Andrew McCaskie

Glasgow

Jim Huntley (ABC Fellow 2012) Catherine Kellett (ABC Fellow 2012) Dominic Meek (ABC Fellow 2008)

Table 2 So uth A f r i ca: P r i mar y Ho sts f o r th e 2 0 1 3 A BC Exch an ge Fe l l owsh i p Site

P r i m ar y A BC Hos t ( s )

Pretoria

Christian Snyckers (ABC Fellow 2012) Tom Mariba (ABC Fellow 2006)

Johannesburg

Andrew Barrow (ABC Fellow 2008) Sebastian Magobotha

Durban

Robert Fraser (ABC Fellow 1996) Basil Stathoulis

Bloemfontein

FP Duplesis Gerhard Greeff

Cape Town

Robert Dunn (ABC Fellow 2004) Michael Solomons Sean Pretorius

details

J. M. Wolf A.Yee B. Wolf M. Provencher R. Gupta M. Ghert G. J. Della Rocca

ABC Travelling Fellowship jmwolf@uchc.edu

BJJ News | I ssue 1 | O ctober 2013

Fellowships

Austrian-Swiss-German Travelling Fellowship 2013

Fig. 1 A visit in the OR of the Princess Grace Hospital, London. (Left to right) Andreas Niemeier, Tobias Renkawitz, Fares Haddad, Rainer Biedermann and Fabian von Knoch

A great start in the UK. etween May 27th and July 3rd 2013 the Austrian-Swiss-German (ASG) travelling fellows visited a number of outstanding academic orthopaedic centres in England, Canada and the USA. The ASG Travelling Fellowship programme, initiated in 1978, is considered the highest distinction within the German-Speaking Orthopaedic Associations and recognises the commitment and dedication to academic orthopaedic surgery of four emerging leaders. One Austrian, one Swiss and two German orthopaedic surgeons

visit or thopaedic centres in England, Canada and the USA, in a programme co-ordinated by the British (BOA), American (AOA) and Canadian (COA) Orthopaedic Associat ions. In return, one Canadian, one British and two American surgeons tour Austria, Germany and Switzerland. The ASG fellows 2013 were: Rainer Biedermann (University of Innsbruck, Austria; paediatric orthopaedics, foot/ankle), Fabian von Knoch (Schulthess Clinic Zurich, Switzerland; adult hip and knee reconstruction), Andreas Niemeier (University of Hamburg,

Germany; adult reconstruction) and Tobias Renkawitz (University of Regensburg, Germany; adult hip and knee reconstruction). We visited 14 different academic orthopaedic departments. The main features of each visit were academic sessions, with presentations by the fellows and their hosts, tours of the clinical areas, campus and research facilities and time in the operating theatre, which allowed excellent scientific and personal discussion. In addition, an impressive social and cultural programme was organised by the hosts.

T. Renkawitz A. Niemeier F. von Knoch R. Biedermann Starting on May 27th in the UK, our first host was Fares Haddad, Professor of Orthopaedics and Director of the Institute of Sport, Exercise and Health at University College, London (UCL) and Editorin-Chief of The Bone & Joint Journal (BJJ). With Rami Kallala, one of Professor Haddad’s research fellows as our guide, we undertook a sightseeing tour of London on a bank holiday, including a visit to ‘The Shard’, the tallest tower (310m) in Western Europe with its spectacular views over the city. The following day, we visited the operating theatres at UCL and the Princess Grace Hospital, enjoying challenging cases of ACL reconstruction, hip arthroscopy and a periacetabular osteotomy (Fig. 1). In the afternoon a scientific symposium was held at the brandnew UCL Inst itute of Spor t, Exercise & Health with talks by the UCL faculty and ASG fellows, which covered a wide range of topics including the mechanisms of disease in subtypes of OA, femoro-acetabular impingement, meniscal augmentation, failure of the unicompartmental knee replacement, component positioning in TKR, measurement of migration and pinless navigation in primary and revision THR, all of which stimulated a vivid exchange of ideas about the on-going research of all presenters. The day ended with an excellent faculty dinner. The following day star ted with a discussion of difficult cases and treatment strategies in total joint replacement with Professor Haddad. Afterwards, it was a special honour to attend a meeting at the editorial offices of The Bone &

BJJ News

Joint Journal in the heart of London, with inspiring presentations by Editor-in-Chief Fares Haddad, Editor Emeritus James Scott and Head of Editorial Publishing Services, Emma Vodden. Topics included the history of the JBJS (Br) and orthopaedic surgery in England, as well as the evolution of the BJJ, academic publishing and current challenges in the peer review process. In the afternoon, we joined Mr Rahul Patel in the operating theatre for a couple of sports medicine cases. In the early evening of 29th May, we continued our trip by train to Nottingham (Fig. 2) where we were welcomed by Mr Peter James, Consultant Orthopaedic Surgeon at Nottingham University Hospital. Next morning, after attending the trauma rounds at Queens Medical Centre, we joined Peter James at Nottingham City Hospital where we were introduced to specific features of the British world of surgery, such as an open Nightingale ward. In the afternoon, Peter James organised a very lively, interesting and enjoyable scientific session on ‘lower limb joint replacement’, with alternating talks by ourselves and Peter James and Andrew Manktelow from the Nottingham faculty. We covered many aspects of lower limb primary and revision re p l a c e m e n t , a n d i n c l u d e d discussion of controversial cases. The day ended with a visit to England’s oldest pub ‘Ye Olde

went to the operating theatres, joining colleagues for a variety of primary and revision upper and lower limb joint replacements. This was followed by an afternoon academic session on the upper extremity, which again included talks by ourselves as well as the Nottingham University faculty (Fig. 3), on topics which ranged from bone-preserving shoulder replacement to the diagnosis and treatment of upper limb tumours and the development and clinical application of the Nottingham Surgilig (LockDown) system. In the evening, Professor Wallace took us to a restaurant close to Sherwood Forest and “home” of Robin Hood where the group enjoyed a spring evening with outdoor drinks and a wonderful selection of venison dishes. On Saturday we used some free time for outdoor sports at the National Water Sports Centre in Nottingham. On Sunday, June 2nd, Professor and Mrs Wallace invited us on a unique canal tour of the British Midlands on their narrow boat ‘Jacana Mist’, which included an exciting training session in steering for each fellow. On June 3rd, we left Birmingham, UK on a flight to Chicago, USA. A more detailed report of the latter stages of the Fellowship will be published shortly in the English and German literature. We would like to express our special thanks to Professors Haddad and Wallace and their

Trip To Jerusalem’ and a delicious ‘Curry night out in Nottingham’, hosted by Peter James. The following day started with a morning session chaired by Angus Wallace, Professor at the Division of Orthopaedic/Accident Surgery, Nottingham University, with a variet y of ‘challenge the ASG fellows’ cases, most entertainingly presented with a touch of British humour. We then

teams in London and Nottingham for dedicating their time, immense hospitality and great friendship to us, which made our time in the UK a perfect start to the tour. We also express thanks to the American, Canadian and British Orthopaedic Associations, as well as the respective national Austrian, Swiss and German Orthopaedic Associations, who made this outstanding 2013 tour possible.

Fig. 2 “Always on the go, bags included”. The four ASG traveling fellows on their way from London to Nottingham

Fig. 3 Exchanging scientif ic ideas during an academic session in Nottingham. (Lef t to right) Tobias Renkawitz, Hernan de la Vega, Brian Holdswor th, David Thyagarajan, Angus Wallace, Andreas Niemeier, Fabian von Knoch, Rainer Biedermann A uthor

details

T. Renkawitz A. Niemeier F. von Knoch R. Biedermann

The Austrian-Swiss-German Travelling Fellowship t.renkawitz@asklepios.com

BJJ News | I ssue 1 | O ctober 2013

Orthopod profile

Dr PC Ho: Renaissance Man

Fig. 1 PC Ho as Young Hong Kong Ambassador, BOA , 1999

t is often my experience that those who have achieved great things in different fields are modest and unassuming about their efforts. They lead by example and are true role models. Such is the case of Dr PC Ho, whom I had the pleasure of meeting, with his wife Magdalene, when I was Secretary of the BOA at its meeting in Glasgow in 1999 and he was the first Young Hong Kong Ambassador (Fig. 1). He had won this honour for his orthopaedic skills but I was also aware he was a world-champion harmonica player. This was borne out by his virtuoso performance on a tiny instrument at our congress dinner. I have been fortunate to have been able to keep in touch with him over the years through many visits to Hong Kong and to admire how his life as an orthopaedic surgeon, musician, family man and sportsman has developed.

As for his orthopaedic career, PC Ho obtained his medical degree from the University of Hong Kong in 1987. He was admitted as Fellow to

D. Jones David Jones reports on a great contributor to orthopaedics, music and more besides

Fig. 2 PC Ho in concer t with King’s Harmonica Quintet and Hong Kong Sinfonietta, 2011

the Royal College of Surgeons of Edinburgh in 1991 and became a Fellow of the Hong Kong College of Orthopaedic Surgeons in 1996. He is Consultant and Chief of the Division of Hand and Microsurgery, and Training Director of the Department of Orthopaedics & Traumatology at the Prince of Wales Hospital in Hong Kong. He is an Honorary Clinical Professor of the Faculty of Medicine and Honorary Tutor of the Department of Music at the Chinese University of Hong Kong. He was President of the Hong Kong Society for Surgery of the Hand in 2008-2010. PC Ho’s main research interest is in arthroscopic surgery of the wrist. He won the award for the best scientific paper at the Annual Congresses of the Hong Kong Orthopaedic Association three times between 1995 and 1998. In 2012, he received the Terry Whipple Prize from the European Wrist Arthroscopy Society to honour his contribution to the advancement of arthroscopic surgery of the wrist. He is currently the deputy editor of the Journal of Wrist Surgery, has over 60 publications and has delivered more

than 230 lectures to learned societies in 55 cities in 27 countries worldwide. He was a founder of the Hong Kong International Wrist Arthroscopy Workshop and Seminar, the evolution of which is reported on page 14. Alongside his medical career, PC showed the same degree of devotion and passion to the other side of his life, harmonica and music. He began his harmonica training at the age of 12 at his secondary school, the King’s College in Hong Kong. He soon obtained numerous awards in the Hong Kong Schools’ Music Festivals in the late 70’s. Witnessing the declining popularity of the instrument in the 80’s, he decided to create a revolutionary form of the performing art by founding the now world-renowned King’s Harmonica Quintet with his school buddies in 1987. The Quintet, consisting of two treble, two tenor and one bass chromatic harmonicas, transcribed classical chamber music into the repertoire of the harmonica ensemble and fully exploited the capabilities of the harmonica as a

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concert instrument. Since 1999 they have also pioneered the commissioning of new works for harmonica quintets. The original repertoire for such quintets has now been expanded to almost 30. In 1997, the Quintet made Hong Kong history by winning the champion title in the Group Category of the World Harmonica Championships in Germany. At the World Harmonica Championships in 1995 and 1997, PC was twice winner, twice runner-up and twice placed third. PC has appeared on numerous occasions with his quintet on the concert platform both locally, including at the prestigious Hong Kong Arts Festival twice in 2000 and 2010, and internationally in 30 cities of nearly 20 countries in America, Europe and throughout Asia. In 2002, he performed James Moody’s “Little Suite” as a soloist with the Hong Kong Philharmonic Orchestra under the baton of Samuel Wong. Over the last 10 years, the quintet has collaborated with all the major professional orchestras in Hong Kong, including the Hong Kong Chinese Orchestra, the City Chamber Orchestra of Hong Kong and the Hong Kong Sinfonietta. The quintet was appointed Artistin-Residence of Radio Television Hong Kong Radio 4 in 2006. They are frequently invited by the Hong Kong Special Administrative Region (HKSAR) Government to showcase this unique performing art at official functions locally and overseas, such as the Ministers’ Dinner for the International Telecommunication Union

Conference in Hong Kong The website of the King’s (2006), the Closing Ceremony Har monica Quintet is of the Beijing 2008 Olympic www.khq.hk Torch Relay in Hong Kong and has links to allow you to see and the HKSAR Government and hear their talents Chinese New Year Trade Promot ion Funct ions in Europe (2007 and 2011). In 2011, the Quintet gave guest performances at with the participation of over 2000 harmonica all six of the superstar pop singer Hacken Lee lovers from all over the world. and Hong Kong Sinfonietta Concerts at the Hong Kong Coliseum and received thunderous In recognition of excellence in his two applause from a total audience of over 70 000 professions, he received the “Ten Outstanding (Fig. 2). Young Persons of Hong Kong Award” in 2002 and the Chief Executive’s Commendation for PC Ho has been the adjudicator and guest Community Service by the Government of the performer for the biennial Asia Pacific Harmonica Hong Kong Special Administrative Region in Festivals since 1996. He appeared in the 2005 2007. World Harmonica Championship in Germany as the first ever jury member from Hong Kong As if all that wasn’t enough, PC is an as well as the conductor at the Hong Kong accomplished hockey player and he and Harmonica Association Harmonica Orchestra in Magdalene are keen cyclists. the Gala concert. His outstanding conductorship was being appraised as “Zubin Mehta of the In spite of all their successes, PC Ho and his harmonica”. In 2012, he was invited to perform family remain modest and unassuming: it is a at the 25 th anniversary concert series of the pleasure to report on the achievements to date Norwegian Harmonica Organization in Norway, of a very special orthopaedic surgeon. partnering his son Leo, who followed in his father’s footsteps and became the World Youth Champion in 2009 and Asia Pacific Champion A uthor details in solo harmonica in 2012. PC was also the D. Jones founding President of the Hong Kong Harmonica Editor, BJJ News Association (2002-2009), and hosted the 5th Asia davidhajones@hotmail.co.uk Pacific Harmonica Festival 2004 in Hong Kong,

Fig. 3a and 3b

PC and Magdalene cycling in Japan, 2013

BJJ News | I ssue 1 | O ctober 2013

Letters



BJJ News : your views

E - ma i l : b jjn ews @ b o n e an d jo in t .o r g.u k

Every little helps

“

At a time of sweeping global austerity, when even the previously sacred public health sectors are fair game for significant cost savings by governments worldwide,1-4 are we, the global orthopaedic community, missing a trick? There are numerous instances where a simple construct of stainless steel wire, screw or bone cement can provide an elegant and extremely cheap solution to an otherwise difficult problem for which there are flashier, high-tech and expensive alternatives. A number of journals publish such technical tips, but costeffectiveness is not their primary intent. If we are to rise to the challenge of providing far more for a lot less in future, should we not establish a global platform from where these ingenious and often local ideas may be shared? For this we see no better forum than the BJJ. The collective technical ingenuity of the BJJ’s expanding readership worldwide must be harnessed for the benefit of ever yone. We humbly request you to consider such a feature.

N. Jayasekera

”

Knee fellow, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals NHS Trust, Exeter, UK

T. Hunter

Clinical fellow, Arthroplasty Unit, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry, UK REFERENCES 1. Houston M, Day M, de Lago M, Zarocostas J. Health services across Europe face cuts as debt crisis begins to bite. BMJ 2011;343:d5266. 2. Hawkes N. Spending cuts or higher taxes are needed to fund NHS in the next 50 years. BMJ 2012;345:e4788. 3. Augusto GF. Cuts in Portugal’s NHS could compromise care. Lancet 2012;379:400. 4. Jennings GL, Macmahon S, Donnan GA. Cuts to the NHMRC budget will undermine the health of all Australians: today and in the future. Med J Aust 2011;194:436-437.

Is it all in the name?

“

I read with interest a recent paper advertised on social media: “No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome”.1 The title caught my eye as, if correct, the findings of this study could have significant impact on the way we treat patients with shoulder impingement. While the title of this paper achieved the goal of drawing in the reader in my case, and would probably have similar ef fects on the media and commissioners, the devil of the paper is in the detail. I have had to read this paper several times to determine if it does what it says on the tin. One of the biggest issues identified is with its inclusion criteria. The inclusion criteria include “attempts to treat with: rest, NSAIDS, subacromial cor ticosteroid injections and regular physiotherapy”. However, there is no clear statement that all patients had corticosteroid injections. The authors do state that all patients had physiotherapy but that this included “massage, heat, transcutaneous nerve stimulation and exercise.” The study included patients from 18 to 60 years old and in fact the youngest patient was just 23 years old. Diagnosis of shoulder impingement was made by a positive Neer’s test (subacromial

lidocaine injection), however, all patients had radiographs and MRI scans but no comment was made as to whether the MRI scans demonstrated features consistent with impingement. Patients were randomised into two groups: physiotherapy, and “combined treatment” i . e . s u rg e r y fo l l owe d b y physiotherapy. The outcome measures include a visual analogue scale for pain as the primary outcome measure, and a shoulder disabilit y questionnaire, but no common shoulder scores such as DASH, SPADI, or OSS. Whereas the groups were randomised there is no description of the demographics of each group and interestingly, despite being diagnosed with shoulder impingement, 11 of 140 patients were described as pain-free at initial assessment. Of the patients randomised to physiotherapy, 25% (18 of 70) eventually had surgery before final assessment. It was also noted that 17% of patients (12 of 70) randomised to surgery refused an operation. Although patients were seen at three months, six months, two years, and five years, only the twoyear and five-year results were provided so no determination could be made as to whether the groups behave differently in the early course of follow-up. The most telling statement in this paper is in the discussion: “In these earlier studies, failure to respond to regular p hys i ot h e ra p y a n d ot h e r conservative treatment was used as an inclusion criterion. In contrast, the present study

aimed to examine whether operative treatment provided any addit ional value to a c o n s e r va t i v e , s t r u c t u r e d exercise treatment.” The crux of the matter is that for most in the UK the indication for surger y in shoulder impingement is failed conser vat ive management which includes corticosteroid injection AND shoulder physiotherapy. By UK standards therefore this study probably over-treated many patients who would have otherwise improved with physiotherapy alone. Indeed in the physiotherapy group only 25% went on to have surgery. The 17% who refused surgery probably didn’t think their symptoms were significant enough to warrant it. Thus the conclusion that arthroscopic acromioplasty is of no benefit is wrong in my opinion. What this study shows, however, is that patients should have failed physiotherapy before being considered for surgery as most seem to do well with physiotherapy alone. Thankfully this is already what most of us already do in practice.

”

N. A. Ferran

Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK

REFERENCES 1. Ketola S, Lehtinen J, Rousi T, et al. No evidence of longterm benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome: five-year results of a randomised controlled trial. Bone Joint Res 2013;2:132-139.

The Oxford Challenging Hip Meeting 2013 Wednesday 20th November The Oxford Hotel See and discuss a variety of difficult cases and scenarios that are faced by both the primary and revision hip surgeon. Our expert faculty will give their own thoughts as to how they will deal with each scenario. For more information or to register, please visit: www.oxcourses.co.uk/hip

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