Bjj news issue 10 by BoneandJoint

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BJJ News from The Bone & Joint Journal

Formerly known as JBJS (Br)

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Issue 10

Notes from the road

Bone setting in the land of Prester John L. Wick

Orthopod’s view

Academic orthopaedics ... on the brink of extinction? J. Palan p2

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BJJ News

Issue 10

from The Bone & Joint Journal

August 2016

Editorial Editorial

A. Ross

Academic orthopaedics: an endangered species

J. Palan

What I wish I had known when I started in orthopaedics

D. C. Jaffray

Anterior cruciate ligament reconstruction: when and how?

S. Ball & A. Williams

ACL reconstruction and the National Ligament Registry: what will it tell us?

S. O’Leary

Current challenges in the surgery of rheumatoid arthritis

B. Ledingham

C. E. Ackroyd

Bone setting in the land of Prester John

L. Wicks

Heterotopic ossification – a model for interdisciplinary working: a report on the Heterotopic Ossification MiniSymposium, Institute Of Translational Medicine, Birmingham, 27 October 2015

N. M. Eisenstein

Report from the International Combined Meeting of the British Hip Society and Societa Italiana Dell’Anca, Milan Italy, November 2015

D. Cundall-Curry

S. Putnis

A response to “Core surgical trainees: a tribe once ‘lost’ and now ‘forgotten’”

J. Tomlinson

Reflections on ‘Current concepts I don’t believe in’

R. Checketts

The early days of the Orthopaedic Training Project, Addis Ababa

G. Walker

M. Laurence

Orthopod’s view

Current Concepts

History The history of the Victoria Cross and Harold Ackroyd VC, MC, MD, 1877-1917: Doctor, scientist and gentleman

Notes from the road

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Fellowships Edited by: Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath

The trauma learning curve: in search of a recognised intercalated trauma fellowship to complement UK training

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Appreciation Frank Horan 1933 – 2015

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A. Ross

Editorial

his year marks the 40th year since I qualified as a doctor and four years since I left the NHS. These anniversaries are, in themselves, of no particular significance except perhaps in one respect. It means that at no time in my professional career have I had to consider taking industrial action on the grounds of pay and conditions. I am not saying for a moment that in the 40 years between 1976 and 2015 the pay and conditions, for junior doctors in particular, were anything to write home about, but they did not spark the degree of protest that has recently been expressed. In November 1975, junior doctors took industrial action when Barbara Castle tried to introduce a new contract which, it was argued, would result in longer hours for poorer pay. Only when both consultants and junior doctors started working to rule, that is doing no overtime and only treating emergencies, did the government back down. When I qualified the following year, basic pay had certainly improved but overtime was still paid at a third of the standard rate (not time and a third, for those in any doubt). Given that the basic rota remained 1:2 or 1:3 on call (1:4 was considered a positive doddle) most junior doctors were working between 80 and 120 hours per week. Why did we tolerate it? First, it was recognised that we were working long hours and consequently we received the support that we needed to do so. The concept of the hospital as ‘house’ genuinely existed. We all lived together in an extended mess system. We each had an on-call room available and accepted the fact that an absent bed leg might be replaced by a pile of surgical textbooks. Cooked food was available around the clock in most hospitals. Some were even known to provide the occasional glass of beer. As important in sustaining us was the existence of the ‘firm’ system. We knew exactly who to call in times of difficulty and there was a well-established chain of command. Consequently, particularly in the better-run hospitals, there was a general sense of camaraderie and mutual support. We were also aware that we were gaining tremendous experience because of the hours we were putting in. If we did the job properly, we would be supported by our consultants and rise, albeit slowly, through the system. By the time we were 35 or 36, we had a consultancy of our own with the benefits that accrued both professionally and financially. What has changed? First, the balance of power between consultants and managers. In the 70s, a number of hospitals were still run by a hospital secretary, often a retired regimental adjutant, a medical superintendent, a senior member of the consultant staff to whom others would defer, and a small group of ancillary administrators. It was all very ‘light touch’. With the introduction of a managerial class, there developed a dual pyramid system with doctors

wishing to ascend one pyramid and hospital managers the other. There was, until recently, little overlap between the two. Gradually, the managers gained the ascendancy and started taking decisions that affected the welfare of the staff in their ‘employ’. What was the effect on junior staff? Little by little, the benefits that had, to some extent, been taken for granted were serially removed. The first to go was the availability of a cooked meal at any time of day or night. The hours became more limited and one increasingly learnt the need to avail oneself of food at prescribed times. This of course preceded the removal of out-of-hours catering services and the advent of the food and drink dispensers prevalent today. Next the on-call rooms started to disappear, on the basis that junior doctors were paid to work at night and therefore had no need for them. Camp beds began to appear in the registrar rooms. In essence, the pastoral support that had enabled my generation to survive otherwise onerous hours was withdrawn. On the professional side, the greatest harm was undoubtedly caused by the establishment of shift working in response to the European Working Time Directive and the wilful destruction of the ‘firm’ system. Not only has this removed the professional support junior doctors need during their training but has made it increasingly difficult for them to gain the training and research experience that they need. There were, of course, other contributory factors and I have simplified history to its most basic. Nonetheless, the gradual withdrawal of the support structure, both professional and pastoral, which made the life of the overworked junior doctor bearable has, in my opinion, substantially given rise to the discontent felt by many. So am I surprised that the junior doctors took industrial action in an attempt to stop the Secretary of State imposing a new contract? Well let me think …

Editor’s note Contract (OED) “A mutual agreement between two or more parties that something shall be done or forborne by one or both; a compact, covenant, bargain; esp. such as has legal effects….”. Note the word ‘mutual’ and consider how it sits with the word ‘impose’.

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Alistair Ross Consultant Orthopaedic Surgeon, Bath, UK alistairrossfrcs@hotmail.com

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J. Palan

ORTHOPOD’S VIEW

Academic orthopaedics: an endangered species many, the term ‘academic orthopaedics’ is an oxymoron. Ortho paedic research has been much maligned in terms of its academic credentials.1 Certainly, much of the research undertaken in the formative years of the specialty consisted of case reports, cohort and case control studies; randomised control trials were few and far between.2,3 The funding for surgical specialties accounts for less than 2% of the £1.5 billion awarded by the National Institute for Health Research (NIHR). Trauma and Orthopaedics (T&O), despite being the largest surgical specialty, has only been awarded 11% (about £12 million) of the £110 million spent on surgery by the NIHR since 1995. Of the 147 surgical studies listed by the NIHR, only 20 (13.6%) were T&O related. Anecdotally, the number of academic T&O posts being created appears to be decreasing, and many medical schools and universities are withdrawing their support for T&O academic departments. Previously established university chairs are not being replaced when the post is vacated and, as a result, in many departments the whole academic structure of senior lecturers, clinical lecturers and the wider research team has been dismantled. Universities are under ever-increasing financial pressure. Unlike other medical specialties such as oncology, cardiology or diabetes, T&O does not attract wider public and celebrity support and with that, funding, despite the fact that the impact of musculoskeletal disease and trauma in society is enormous. Over eight million people in the UK have osteoarthritis; trauma is the number one cause of death in people under the age of 40 years. Unfortunately, arthritis just isn’t ‘sexy’ compared to other diseases or conditions. With fierce competition for national training numbers, many core surgical trainees do not wish to commit themselves to a higher research degree without a guarantee of a T&O training number in the future. Only a relatively small figure pursue careers in academic orthopaedics and, compared to other surgical specialties, a smaller proportion of trainees undertake a higher research degree such as an MD or PhD.4 Even once the trainee has secured a training

number, it is often difficult to engage in meaningful and high-quality surgical research as they rotate from post to post every six months or so. High-quality research needs time and resources. Those taking part in large clinical trials may not see their efforts translated into publications or presentations for years. It is therefore unsurprising that for most T&O trainees, pursuing an academic career does not register on the radar. Indeed, even for those who would like to undertake a higher research degree, the process can appear quite daunting, with difficulties in obtaining research grants and securing research fellowships and funding.5 There have been a number of developments that may help improve the outlook for academic orthopaedic surgery. The development of joint and other national registries have paved the way for the routine collection of large amounts of data about common procedures. The National Joint Registry (NJR), now in its eleventh year of operation and with almost two million joints registered, is the largest arthroplasty registry in the world. Analysis of NJR data has also resulted in numerous publications, including some high-profile studies in high-impact factor journals such as the Lancet.6,7 This helps raise the profile of T&O research in the wider scientific community and build the case for attracting research funding into T&O. The creation of NJR research fellowships, in conjunction with the

Royal College of Surgeons of England, has encouraged T&O trainees to undertake higher research degrees by providing funding for their endeavours. Over the last few years, there have been a significant number of multi-centre, randomised control trials in T&O which have attracted NIHR funding and other large grants. Proximal Fracture of the Humerus Evaluation by Randomisation (PROFHER), Distal Radius Acute Fracture Fixation Trial (DRAFFT), UK Heel Fracture Trial, Total or Partial Knee Arthroplasty Trial (TOPKAT) and the UK Fixation of Distal Tibia Fractures (UKFixDT) are just some examples of the increasing number of pragmatic multicentre RCTs being undertaken in the UK. Such studies show that T&O is fully capable of producing high-quality research with large patient numbers from multiple hospitals. Furthermore, such studies provide evidence of a research pedigree and track record, enabling subsequent grant applications by the research teams to be more successful in the future. Success begets success. The development of trainee-led research networks in T&O, such as the Collaborative Orthopaedic Research Network (CORNET) and the British Orthopaedic Network Environment (BONE) provides an opportunity for T&O trainees to engage in audit and research studies across the UK.8 This can help mitigate the problem of trainees having to rotate in and out of different hospitals during their training programme and thus never having an opportunity to get involved in meaningful and high-quality research studies. Such networks provide a platform for trainees to generate research ideas (through audit and systematic reviews), get advice and support on developing a research idea and link up with other trainees across different regions to deliver a successful, multicentre research study. Our general surgical colleagues at the London Surgical Research Group (LSRG) have already developed a successful model across different surgical specialties which has generated numerous peer-reviewed publications, as have other trainee-led research networks. BONE and CORNET aim to follow in their footsteps and in doing so, encourage a new

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generation of T&O trainees to get involved in research. Finally, the creation of the BOA Orthopaedic Surgery Research centre with the support of the York Clinical Trials Unit will go some way to helping orthopaedic surgeons develop their research ideas in order to attract larger grants. By providing access to study trial experts such as methodologists, epidemiologists and statisticians, T&O research studies can hopefully compete with other specialties in attracting a larger slice of the research grant pie. The future of academic orthopaedics will ultimately depend on being able to attract T&O trainees into research, to develop and deliver high-quality multicentre RCTs which attract significant grant funding. Only then will universities sit up and take notice and support T&O as an academic specialty. In order to do so, we need to collaborate, not only with other T&O surgeons, but with other specialties such as cardiology, diabetes medicine and general practice. Many patients with musculoskeletal problems also have other conditions such as obesity, cardiac pathology and diabetes. We need to look at the

bigger picture and examine the impact of such conditions on musculoskeletal diseases such as osteoarthritis. By linking up with other specialties and developing joint multidisciplinary research studies, T&O can start to attract the very largest research grants which will help to secure the future of academic orthopaedics.

6. Hunt LP, Ben-Shlomo Y, Clark EM, et al; National Joint Registry for England, Wales and Northern Ireland. 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013; 382:1097-104. 7. Smith AJ, Dieppe P, Vernon K, Porter M,

In memory of Andrew Sprowson

Blom AW; National Joint Registry of England and Wales. Failure rates of stemmed metal-on-

References

metal hip replacements: analysis of data from the

1. Horton R. Surgical research or comic opera:

National Joint Registry of England and Wales. Lancet

questions, but few answers. Lancet 1996;347:984-5.

2012;379:1199-1204.

2. Lim HC, Adie S, Naylor JM, Harris IA.

8. Rangan A, Jefferson L, Baker P, Cook L.

Randomised trial support for orthopaedic surgical

Clinical trial networks in orthopaedic surgery.

procedures. PLoS One 2014;9:e96745.

Bone Joint Res 2014;3:169-74.

3. Rangan A, Brealey S, Carr A. Orthopaedic trial networks. J Bone Joint Surg [Am] 2012;94-A (Suppl 1):97–100. 4. Sherry P, Pietroni M. Research in orthopaedic training: the trainees’ experience. Ann R Coll Surg Engl 1995;77(suppl):61-3. 5. Rankin KS, Sprowson AP, McNamara I, et al. The orthopaedic research scene and strategies to improve it. Bone Joint J 2014;96-B:1578-85.

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Jeya Palan, Trauma and Orthopaedic Specialty Registrar, University Hospitals Leicester NHS Trust, UK jp314@le.ac.uk

D. C. Jaffray

What I wish I had known when I started in orthopaedics

have always been naïve and impulsive. Luck and fate guided my career rather than design and planning, and I would not have wanted it any other way. Nobody from my background would gain entry to medical school now. Thankfully there were no interviews in Aberdeen, and it was all a matter of getting top marks. Luck allowed me to escape from what was and still is the worst school in Aberdeen by passing the eleven-plus examination. A latent cerebellar haemangioblastoma in the floor of my fourth ventricle would have killed me in later life, but a kick in the back of the head playing rugby union at grammar school burst it in the prime of life at age 16. My mother made the diagnosis after the GP had tried a suppository for constipation and thereafter wrenched my neck, rendering me unconscious in due course. He was awarded the MBE for services to general practice. I would reject any honour as it would remind me of a suppository.

Admitted as a myocardial infarction, thankfully someone listened to my mother’s diagnosis of a brain tumour. Bob Fraser, the neurosurgeon, came in his old gardening coat. The lift taking me to theatre was stopped to allow Bob to perform

a tracheotomy on the lift floor. Could you imagine that today? Three resuscitations and many hours in theatre eventually led to an oil ventriculogram pointing to a blockage in the aqueduct of Sylvius. The vessel was clipped after considerable retraction of my occipital lobes, which presumably was the reason for my blindness in the days ahead. Bob reassured my mother as best as he could. She offered to buy him a new coat.

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Blind and unable to talk, my only means of communication in intensive care was to try to write. My mother kept the child-like means of communication, an example of which is illustrated. Twenty-eight days later I literally staggered out of Aberdeen Royal Infirmary. Many years later I had dinner with Bob Fraser. He had suffered a massive stroke and could barely speak. His eyes lit up when he saw me. “You were very lucky,” he said. His perseverance saved me. Today, with the same scenario, I would not stand a chance. Lying in bed in hospital, blind and struggling, I awoke to the news of the Aberfan disaster. Tom Jones sang ‘The Green Green Grass of Home’. I opened my eyes and I could see. I cried for one of the few times in my life. I thought then that medicine was for me. After all one went into hospital on the verge of death, had an operation and all was well. These were my thoughts going into medicine. Naïve? Late in medical school, fate and luck struck again. I was married aged 21 to the best woman in the world. This was to prove a life-support through seventeen homes during training, and travel to two continents. That just does not happen today. The registrars now go home on Friday nights to childcare duties, rather than keep me company in the pub. On the registrar rotation in Aberdeen, I was gaining the old way of experience in many specialties, even in neurosurgery where I quickly realised that miracles like mine were exceptional and rare. This was invaluable, though hard to cope with many one in one, or one in two rotations. Unimaginable today, but it certainly toughened you up. Fate was again to come into play. Taken aside and advised that my strong accent was unacceptable, my response was only two words. The job section of the BMJ was often left open for me. Andrew Smith, my predecessor, had gone to a place called Oswestry the year before and, lo and behold, there was an advert for orthopaedic registrars in Oswestry. Luck or fate? I arrived in Oswestry the night before the interview. Too much whisky that night with Andrew meant that I turned up for the interview not having visited the hospital or even spoken to any of the staff. Last of the eight candidates, I answered strange questions the best I could. “Do you speak Gaelic?” “No,” I replied, “I am still struggling with English”. Pity and astonishment

probably swayed the committee. Within three months of working in North Wales, my attention was brought, by chance, to a request from Oswestry for someone to go to Australia and Hong Kong. Professor O’Connor was delighted in my interest, and so was my wife when I told her to stop house-hunting. We were off abroad for two years. Impulsive and naïve. However, it was to prove the best move we made. Luck again came into play. Today’s trainees are planning their fellowship years in advance, and to specific centres. This has to be the case as a result of regulations and bureaucracy. I would not like to be in this situation, knowing what I know now. The spontaneous radical movements that I took were unusual, but were possible in my day. If I was starting again today, knowing what I know now, then I reckon I would have been more radical. The only thing stopping me from going to Vellore in India to the Christian Centre after two years in Australia and Hong Kong was my son reaching school age; my wife had also been through a lot. I had learned that going to the best has to be the only way, but that there were limits. Sheer luck had brought me to Oswestry. At that time it was like the United Nations. Brits were in the minority. You learn so much working with people from other lands and cultures and the teaching set-up was hypnotic. I was captivated and was later put in a position to develop it into one of the foremost teaching programmes, as described recently in the Journal of Trauma and Orthopaedics. The Silver Scalpel Award was a tribute to Oswestry. I doubt if I could have achieved this without the unique ambience of Oswestry. Again, luck and chance had brought me there. I could not have anticipated or planned to move from Scotland. I would never go into any management position now. Two years into my consultant career, I was made Clinical Director because there was no-one else, a post that I held for fifteen years. A complete lack of diplomacy did not seem to be a barrier. Nowadays, political correctness and regulation is a total barrier to progress. I had more or less a free rein. With no computers and no emails, I would speak endlessly to colleagues and relied on common sense and, above all, harmony. These are impossible objectives today and so, if I had my time again I would stick to clinical matters. Knowing what I know now, the same antipathy would apply to any committee work. I tried

my best on the BOA Council and the SAC, but just upset a lot of people. I do not think a personality change and diplomacy would be possible even with hindsight. Incest is not a good idea. Knowing what I know now tells me that I was lucky to meet so many talented people throughout England, Australia and Hong Kong as well as, in particular abundance, in Oswestry. Today, training programmes are so regional. I was lucky to go so far and wide to broaden my horizons. Today, that scope for development is very difficult. Perhaps every surgeon becomes conservative with age and scarring. If I had my time machine and could start again with my knowledge of the natural history of many orthopaedic conditions and, in particular, my specialty of spinal disorders, I would be more conservative. My contributions would be more like the recent publications on the rapid mobilisation of burst fractures and the natural history of massive disc protrusions. Starting again with an old head on young shoulders would help me clinically, but I would not be going back to the NHS when I started. Orthopaedics is a vocation and not a vacation. Illness does not take a holiday or have a worklife balance. Thank God Bob Fraser did not have a job plan. Thank God he did not work on shifts. Thank God he did not obey protocols and pathways of care. Thank God he did not bother about bare below the elbows. Thank God there were no chief executives, bureaucrats, quangos and such like, too many of whom are on salaries greater than the Prime Minister. Bob was a true professional. A consultant as I understood it. Starting now as a consultant would be too difficult, even with the benefit of hindsight. I would be a mere employee answerable to people, who in my day could not have crossed the front door of a medical school. So, I have had my time and even if I could go back in a time machine, my experience would not count for much in the modern world. My mother had it right when she told me, “Son, you cannot fart against thunder”. A uthor

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David C. Jaffray, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK davidjaffray@ aol.com

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current concepts

Anterior cruciate ligament reconstruction: when and how? Indications for surgery Most young active people will do well after a good anterior cruciate ligament (ACL) reconstruction. A bad operation can, however, result in outcomes that are inferior to nonoperative management. It is clear that not every patient needs to have an ACL reconstruction. However, we are concerned about some high-profile articles that suggest that much less ACL reconstruction surgery than is currently being undertaken is appropriate.1 Unfortunately, in keeping with a number of ‘anti-surgery’ publications, these articles do have methodological flaws but have been seized upon by major non-specialist medical journals for publication, and are therefore at risk of being taken at face value. Those of us practising during the early 1990s will remember many patients who ultimately came for help only once awful damage secondary to ACL deficiency had occurred. It would be a terrible shame to go back to that. One problem with publications in major journals which suggest that ACL reconstruction is not needed, is that health care providers take note of them. We suggest that a suitable approach to offering ACL reconstruction surgery is used. Following an acute ACL rupture, the vast majority of young active patients who want to play sport should be offered reconstruction surgery. Even sedentary patients of a young age (< 30 years) should be seriously considered for this. In patients over 40 years of age, we would certainly recommend consideration of a non-surgical approach initially, with surgery later if required. This would be the same for sedentary patients in their 30s. It is however essential to understand that there is risk associated with a non-operative pathway, and that such a pathway is not a passive process. Patients being managed nonoperatively should initially be managed with a supervised programme of physiotherapy to enable them to recover from the injury, and then acquire strength and neuromuscular control in the limb before commencing a lifelong maintenance programme. If at any stage there are symptoms of instability, such as lack of

trust in the knee, giving way, recurrent effusions or mechanical symptoms, patients should be offered the option of surgical reconstruction. We must emphasise that a knee that is unstable will deteriorate. However, if patients do not have any symptoms of instability then they can safely continue with a non-operative approach.

Timing of surgery Donald Shelbourne2 published seminal work, which meant that for a long time surgeons would never operate until three weeks had elapsed from injury. While this was helpful at the time, the reality is that it is safe to operate as soon as the knee has full active extension, is bending freely to over 90° and is ‘quiet’, with only a small effusion and little obvious inflammation. The spectrum of injury related to ACL rupture is considerable and some knees can be operated upon within a day or two of injury whereas others take much longer than three weeks. Failure to wait until the knee is ‘quiet’ will lead to an unacceptable risk of stiffness (especially fixed flexion deformity), which can be very problematic and hard to treat.

Choice of graft The choice of graft continues to cause debate. Autograft is our first choice for the reasons explained below. In recent years there has been a resurgence of interest in synthetic ACL grafts and allograft. Synthetic ACL grafts used in the 1980s disappeared due to problems with early failure, and complications related to synovitis and bone cyst formation. A few years ago a very well-publicised case of an Australian Rules football player in Sydney led to increased usage of synthetic (polyester) grafts in Australia. Perhaps not surprisingly, it was mainly younger surgeons that took this on since they had never seen the problems of the grafts used in the 1980s. The very early results were encouraging, but due to very high failure rates at about three years, the Australian Knee Society has issued a statement on its website suggesting limiting the use of single bundle synthetic ACL reconstructions. We

S. Ball A. Williams

therefore do not advocate the routine use of such grafts. The situation may be different for their use in PCL reconstruction. Allograft is an established choice for ACL reconstruction, particularly in America. It does, however, seem very clear that the re-rupture rate is much higher. The MOON (Multicentre Orthopaedic Outcomes Network) group reported a four-fold increase in re-rupture with allograft over autograft.3 Another study on recruits to the US military academy found a re-rupture rate 7.7 times higher in those who had allograft than those with an autograft reconstruction.4 It would seem that the risk of re-rupture is lower in older patients, but we would question whether or not they actually need ACL reconstruction: graft survival may only reflect a relative lack of graft stress. The results of surgery as reported by a surgeon are only applicable to that surgeon’s practice, and perhaps not to others. The most demanding group to deal with who have the highest re-rupture rates are, of course, athletes. While allograft may work in a sedentary, relatively inactive patient, our experience is that the re-rupture rate in professional athletes (such as footballers) is unacceptable. The only absolute indication for allograft is in elite ‘straight-line’ athletes who rely on power such as sprinters or rowers. We do use allograft in this scenario. These athletes do not subject their knees to rotational load, so the weaker graft is acceptable. For the reasons above, our practice is firmly based around the use of autograft. In the 1980s and 1990s, a middle-third patellar tendon graft became a reliable option, but one associated with significant complications, particularly of anterior knee pain. As a result, by the mid-1990s hamstring grafts were being widely used and have become increasingly popular. The Swedish registry reported that 95% of primary ACL reconstructions in 2012 were with hamstring autograft.5 Similarly we use hamstring autograft for most of our patients: for those who have relatively small hamstrings we will routinely use a ‘triple hamstring graft’ to produce a six-strand graft. The technique for tripling the hamstring graft is illustrated in Figure 1.

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Fig. 2. Patella tendon harvest. Note that the distal bone block is harvested first then the middle third of the tendon is lifted to enable the patella bone block to be ‘undercut’.

Fig. 1. A technique for tripling semitendinosus and gracilis. The hamstrings are detached and passed through the EndoButton. The distal end of the hamstrings is held with a clip. The other end is passed around the clip and sutured to the EndoButton loop. Appropriate adjustments are made to achieve equal tension in all limbs of the graft. The suture is continued as a whip stitch from the EndoButton down the graft. As shown, a separate stitch is inserted to enable the graft to be tensioned. We are also using an increasing amount of patellar tendon. If one simply thinks about the robustness of the graft and the rate of rerupture, then patellar tendon is arguably the best graft. Furthermore, complications surrounding anterior knee pain have been greatly reduced with modern surgical technique. The surgical techniques of the early 1990s involved the use of poor-quality saws which involved more trauma in harvesting bone blocks, the practice of taking excessively large bone blocks and (probably most importantly) the use of open surgery with excision of the fat pad to get access through the interval in the patellar tendon to the joint. The fat pad is highly-innervated and has a high concentration of stem cells. As a consequence it has a tendency to form scar that can be very painful. When this is combined with poor rehabilitation, it is not surprising that anterior knee pain rates of 19% and a fixed flexion deformity rate of 24% have been reported.6 Due to these complications we suggest such ‘open ACL’ surgery is now obsolete. Current mid-third patellar tendon graft harvesting involves either a single midline incision or a two-incision technique combined with the use of high quality saws, to remove a 25 mm bone block from the tibial tuberosity and a 20 mm block from the patella. The average width of the patellar bone block is between 9 mm and 10 mm, and that of the tibial bone block between 10 mm and 11 mm. Rather than taking a big wedge of bone out of the patella, if the tibial bone block is elevated first then the bone block on the patella can be

undercut (Fig. 2), which reduces damage to the patella. Care is taken not to touch the fat pad at all. With this technique, significant problems with anterior knee pain are rare. Nevertheless, in the early stages of recovery there will be more difficulty in engaging the quadriceps muscle, and perhaps a slower return to work due to discomfort than occurs with hamstring grafts, which we therefore prefer in non-athletes. The senior author (AW) has an unusual practice with a high volume of professional athletes. Over half of his ACL reconstructions are in this group in whom gross outcome data, such as graft re-rupture rates, is easy to collect, with 100% follow-up. For professional footballers in the UK, the re-rupture rate of hamstring tendon graft is approximately double that of patellar tendon (see below). For other sports such as rugby, the re-rupture rate of professional players remains acceptable (6% in senior author’s hands).

Single- or double-bundle reconstructions Four years ago, double-bundle ACL reconstruction was popular. Although there was a theoretical biomechanical advantage of two bundles (anteromedial (AM) and posterolateral (PL)), very few surgeons have continued with this. Even leaders in that field have largely dispensed with this procedure, as they were unable to demonstrate any clinical advantage, and thus the increased technical difficulty and complications could not be justified. Problems encountered were inadequate graft size, graft

impingement, failure to place grafts in appropriate positions (particularly on the femur) and difficulties in revision when dealing with four bone tunnels.

Fixation devices Given the ingenuity of orthopaedic surgeons, there exists an endless supply of new fixation devices of variable quality. We will not cover these in detail. Bioabsorbable products have been popular as patients and surgeons are seduced by the idea that the device will disappear and be replaced by bone. However, the evidence for this is limited. Most absorbable implants take an extremely long time to fragment and ‘disappear’ and, of course, most do not actually disappear and remain present as a void filled with fibrous tissue. They are also significantly more expensive: in our opinion, titanium and MRI-compatible metal screws are not only cheaper, but equally effective without the risks of breakage or biological reaction. Suspensory fixation devices fix the graft away from the apertures in the joint, and therefore the working length of the soft-tissue graft is increased. Although this could increase graft stretching, they do seem to work well. The graft incorporates at the opening of the tunnel into the joint within a matter of weeks. This is illustrated in a case report in which the tibial interference screw of a hamstring graft was removed at seven weeks after surgery. Despite having no fixation device in the tibial tunnel, the graft healed satisfactorily.7

Tunnel placement ACL reconstruction was made reliable not only by the development of the middle third patellar tendon graft, but also by improvements in tunnel positioning. The aim was to avoid graft impingement on the femoral intercondylar notch during knee extension, and to achieve

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The role of a lateral tenodesis

Fig. 3. Basic terminology of the lateral wall of the notch. It is important to appreciate the knee is flexed to 90° and therefore ‘deep’ = ‘proximal’, ‘shallow’ = ‘distal’, ‘high’ = ‘anterior’ and ‘low’ = ‘posterior’. graft isometry. As a result, the tibial tunnel was placed more posteriorly to avoid impingement of the graft, and the femoral tunnel was placed ‘deep and high’ in the notch. Although this led to the operation being relatively reproducible, persisting instability was noted to be the cause of poor results in some patients, perhaps because these tunnel positions lead to a relatively vertical graft in the sagittal and coronal planes. The concept of the double-bundle ACL arose from a study of the bundle anatomy of ACL and its sites of attachment to the femur and tibia.8 When it became apparent that doublebundle reconstructions did not provide the advantage that had been hoped for, understandably, it was thought that placing the femoral tunnel at the centre of the femoral ACL footprint would be logical. The laboratorybased experimentation that has suggested double-bundle reconstructions might be biomechanically advantageous, was reproduced for a single-bundle placed in the centre of the femoral tunnel.9,10 This ‘centre-footprint’ position for femoral graft placement has been popularised and termed ‘anatomical’. Unfortunately it would seem that the risk of graft rerupture may be higher. In the senior author’s experience when dealing with professional football players, graft re-ruptures have doubled! When moving from a traditional AM

bundle femoral position to the ‘anatomical’ (centre-footprint) position, the rupture rate for four-strand hamstring rose from 6.9% to 17%, while that for patella tendon rose from 4.5% to 10.2%.11 This has also been intimated from the Scandinavian registries.12 Although it is logical to place the graft in the centre of the femoral attachment of the ACL, it may be that the position of the fibres does not select those which carry most of the load. A number of recent anatomical and biomechanical studies have suggested that the most important fibres of the ACL are situated deep and high in the ACL footprint.13,14 Our practice has therefore reverted to a more traditional femoral tunnel position within the footprint of the AM bundle of the ACL, high and deep in the notch. When considering tunnel position it is essential to understand the terminology in an anatomical sense. Surgeons view the intercondylar notch with a flexed knee at 90° or deeper flexion. The term ‘deep in the notch’ refers to a proximal position. Shallow equates to distal, low equates to posterior and high equates to anterior. We still find the ‘clock face’ analogy useful, but do acknowledge that this is a two-dimensional concept and therefore does not reflect the depth of placement of the graft. Nevertheless, while appreciating this, we believe it is a useful terminology (Fig. 3).

In the last few years considerable interest has been directed at the lateral soft-tissues of the knee. The stimulus for this was the description of the anterolateral ligament by Claes et al.15 This was not new, and had previously been described by many authors,16-19 but has been clarified by this new work. Dodds et al20 (Imperial College, London) described the ligament in more detail, including its femoral attachment; Claes has recently confirmed their findings.21 Despite the interest in this ligament, it would appear that its role in resisting internal tibial rotation, and therefore pivot shift, is minimal. Further work at Imperial College suggests that the main restraint to internal rotation of the tibia and the pivot shift phenomenon is actually the iliotibial band.22 The ACL is the main restraint to anterior translation of the tibia, but only has a significant role in resisting internal rotation of the tibia close to full extension . Because of this work, surgeons are now considering lateral surgery in addition to intraarticular reconstruction of the ACL. Traditionally, tenodeses were used but fell out of favour when they were thought to be superfluous to intra-articular ACL reconstruction and possibly associated with, or leading to, lateral osteoarthritis. For a period after the popularisation of middle-third patellar tendon ACL reconstruction, many surgeons would combine this with a lateral tenodesis such as a MacIntosh procedure. Its popularity waned as it was felt to be unnecessary, but biomechanically and clinically it appears to be very effective.23 It presumably protects the intra-articular ACL graft during its healing phase and then provides a secondary restraint to pivot shift on return to activity. Our current practice, therefore, is to undertake a lateral tenodesis in all revision cases and in primary patients who are perceived to be at greater risk of re-rupture, such as those who are still growing, hyperextenders and those with marked laxity. In immature patients, the graft can be fixed distal to the growth plate. From the research at Imperial College, it has been shown that the graft used for a lateral tenodesis (usually iliotibial band left attached to Gerdy’s tubercle) should be taken deep to the LCL before its attachment to the lateral femur (Fig. 4). In the immature knee, radiographs are used to ensure that the suture anchor is distal to the growth plate when fixing the graft to the lateral femur. Proximal fixation would cause a tether across the growth plate.

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Fig. 4. Lateral tenodesis with a strip of iliotibial tract (ITT) passed beneath lateral collateral ligament (LCL).

tract or anterior oblique band avulsion. Radiology

2012;40:1242-1246.

2001;219:381-386.

5. Kvist J, Kartus J, Karlsson J, Forssblad M.

18. Vincent JP, Magnussen RA, Gezmez F,

Results from the Swedish national anterior cruciate

et al. The anterolateral ligament of the human

ligament register. Arthroscopy. 2014;30:803-810.

knee: an anatomic and histologic study. Knee Surg

6. Sachs

Sports Traumatol Arthrosc 2012;20:147-152.

RA,

Daniel

DM,

Stone

ML,

Garfein RF. Patellofemoral problems after ante-

19. Irvine GB, Dias JJ, Finlay DB. Segond frac-

rior cruciate ligament reconstruction. Am J Sports

tures of the lateral tibial condyle: brief report. J Bone

Med 1989;17:760-765.

Joint Surg [Br] 1987;69-B:613-614.

7. Logan M, Williams A, Myers P. Is bone tun-

20. Dodds AL, Halewood C, Gupte CM,

nel osseointegration in hamstring tendon autograft

Williams A, Amis AA. The anterolateral ligament:

anterior cruciate ligament reconstruction impor-

anatomy, length changes and association with the

tant? Arthroscopy 2003;19:E1-E3.

Segond fracture. Bone Joint J 2014;96-B:325-331.

8. Zantop T, Wellmann M, Fu FH, Petersen

21. Kennedy MI, Claes S, Fuso FA, et al. The

W. Tunnel positioning of anteromedial and

anterolateral ligament: an anatomic, radiographic,

posterolateral bundles in anatomic anterior cruci-

and biomechanical analysis. Am J Sports Med

ate ligament reconstruction: anatomic and radio-

2015;43:1606-1615.

graphic findings. Am J Sports Med 2008;36:65-72.

22. Kittl C, El-Daou H, Athwal KK, et al.

There have been considerable changes in the surgical management of ACL deficiency in the last few years. The key changes have been that the synthetic ACL graft had a brief re-appearance but seems to have disappeared, as has double-bundle ACL reconstruction. It appears that a femoral tunnel placed deeper and higher in the notch may have a lower rate of re-rupture than in the central, so-called ‘anatomical’, position. There is considerable interest in concurrent lateral procedures, but further followup is needed to see whether these stand the test of time. ACL reconstruction is an established and effective treatment for ACL deficiency. Clearly it is not needed for every patient with an acute ACL rupture, but will benefit most. Reports to the contrary run the risk of leaving a large number of patients with an unstable knee that deteriorates, with progressive failure of the menisci and joint surface.

9. Ho JY, Gardiner A, Shah V, Steiner ME. Equal

Williams, Amis A. The role of the anterolateral

kinematics between central anatomic single-bundle

structures and the ACL in controlling laxity of the

and double-bundle anterior cruciate ligament

intact and ACL-deficient knee. Am J Sports Med

reconstructions. Arthroscopy 2009;25:464-472.

2016;44:345-354.

10. Kato Y, Ingham SJ, Kramer S, et al. Effect

23. Sonnery-Cottet B, Thaunat M, Freychet B,

of tunnel position for anatomic single-bundle ACL

et al. Outcome of a combined anterior cruciate

reconstruction on knee biomechanics in a por-

ligament and anterolateral ligament reconstruction

cine model. Knee Surg Sports Traumatol Arthrosc

technique with a minimum 2-year follow-up. Am J

2010;18:2-10.

Sports Med 2015;43:1598-1605.

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1. Frobell RB, Roos EM, Roos HP, Ranstam J,

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Lohmander LS. A randomized trial of treatment

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for acute anterior cruciate ligament tears. N Engl J

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2. Shelbourne KD, Wilckens JH, Mollabashy

14. Kawaguchi Y, Kondo E, Takeda R, et al.

A, DeCarlo M. Arthrofibrosis in acute anterior cru-

The role of fibers in the femoral attachment of the

ciate ligament reconstruction. The effect of timing

anterior cruciate ligament in resisting tibial dis-

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placement. Arthroscopy 2015;31:435-444.

Med 1991;19:332-336.

15. Claes S, Vereecke E, Maes M, et al.

Summary

United States Military Academy. Am J Sports Med

11. Clatworthy M. Femoral tunnel placement in ACL reconstruction: central footprint vs AM Bundle. ISAKOS Newsletter. Summer 2015; Volume II:26-31. https://www.isakos.com/assets/newsletter/sum15. pdf (date last accessed 1 June 2016). 12. Rahr-Wagner

Thillemann

TM,

Pedersen AB, Lind MC. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy 2013;29:98-105. 13. Śmigielski R, Zdanowicz U, Drwięga M,

3. Kaeding CC, Aros B, Pedroza A, et al.

Anatomy of the anterolateral ligament of the knee.

Allograft versus autograft anterior cruciate ligament

J Anat 2013;223:321-328.

reconstruction: predictors of failure from a MOON

16. Vieira EL, Vieira EA, da Silva RT, et al. An

prospective longitudinal cohort. Sports Health

anatomic study of the iliotibial tract. Arthroscopy

2011;3:73-81.

2007;23:269-274.

4. Pallis M, Svoboda SJ, Cameron KL, Owens

17. Campos JC, Chung CB, Lektrakul N,

BD. Survival comparison of allograft and autograft

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anterior cruciate ligament reconstruction at the

tomic and MR imaging evidence of an iliotibial

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Simon Ball , Fortius Clinic, UK Andy Williams, Fortius Clinic, UK Simon.Ball@fortiusclinic.com Andy.Williams@fortiusclinic.com

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S. O’Leary

current concepts

ACL reconstruction and the National Ligament Registry: what will it tell us?

njury to the anterior cruciate ligament (ACL) is common and ACL reconstruction is the second most frequently performed major knee operation after total knee arthroplasty. The annual incidence of ACL injury in the UK is unknown. Data from the 2014 annual report of the Swedish ACL registry, recorded an incidence of 1 : 80 000, suggesting that approximately 54 000 ACL injuries occur per annum in the UK. If only 50% of these patients need surgery, this would equate to 27 000 primary ACL reconstructions each year, a number 3.5 times greater than the number of unicompartmental knee arthroplasties undertaken. The increased risk of developing degenerative change in the knee after rupture of the ACL is known (especially if associated with meniscal or cartilage injury), but there are few large studies that report patient function after ACL reconstruction. There is also no clear understanding of the rate of repeat surgery after ACL reconstruction (for all causes including graft rupture) but it could be as high as 20%; the natural history of non-operatively managed ACL injury is again largely unknown. While it is widely reported that the incidence of graft rupture is significantly higher in younger, more active patients, especially women, a better understanding of which group of patients, which graft/fixation types and which sports are associated with increased risk of re-injury is needed. Although operative activity in the NHS is recorded by the Hospital Episode Statistics (HES) system, this data is known to be inaccurate, with little surgeon input or validation. HES data may, however, be used by other agencies to generate ‘outcome measures’ which are made publically available to compare surgeons and hospitals. It is thought that approximately half of all ACL reconstructions in the UK are undertaken in the private sector, but there is currently no comparable method of coding and recording private sector activity to allow comparison with NHS data. Additionally, neither sector has any system to record the patient-reported functional outcomes of ACL reconstruction. Arthroplasty publications suggest poorer outcomes with lower volume surgery, but it has yet to be

determined as to whether similar trends occur with soft-tissue knee surgery. The UK National Ligament Registry (NLR) was started in March 2013 in an effort to address some of the many outstanding questions surrounding ACL surgery and to provide accurate data capture for patient demographics and functional outcome after primary ACL reconstruction. The chosen outcome measures were the Knee injury and Osteoarthritis Outcome Score (KOOS), the subjective International Knee Documentation Committee (IKDC), EuroQol (EQ5D) and the Tegner activity score. These scores allow comparison and communication with existing registries as well as allowing potential ‘generic health benefit’ comparisons to other non-orthopaedic procedures. Further operations and complications are also recorded. In time, it is planned to extend the registry to capture data for revision procedures and for patients with ACL injuries managed nonoperatively, making it a more comprehensive ACL injury registry, and eventually the ‘go to’ place for information about ACL injuries. The registry may also provide patients with an element of ‘quality assurance’ which extends beyond functional outcome to surgical numbers, patient selection, rehabilitation, prostheses and surgical techniques. The main role of the NLR must be to encourage the development of better surgical practice for patients. In doing so it will also provide a framework for surgeons to collate and audit their results, satisfying the modern requirements of appraisal and revalidation. All aspects of the injury and intervention are recorded, including differing graft options (including the apparent re-emergence of synthetic grafts and primary ligament repair) and fixation types, allowing equitable comparison. Key to the success of the registry is the involvement of all stakeholders and it is important that patients, surgeons and industry are involved, feel valued and benefit from the process. The NLR website (www.uknlr.co.uk) has been developed for both patients and professionals alike, and links to the online data recording system utilising the Amplitude software (Bluespier/Amplitude Clinical, Droitwich, UK).

The NLR team has produced patient and surgeon information videos, a QR code and is developing a mobile platform for use with tablets and smartphones. The reports platform allows surgeons to generate bespoke reports to audit their own data and generate outcome reports for interested patients, as well allowing the production of larger comparative reports for units or the national cohort. The annual report is to be published to coincide with the British Association for Surgery of the Knee (BASK) annual meeting, and the first annual report from 2015 is available to view from the website. The NLR is currently developing a reporting tool specifically for appraisal and revalidation, which will allow a concise report of all ACL activity. The NLR is independent of both government and private medical insurance company support and receives no public funding, which protects it from Freedom of Information requests. Financial support is provided by ten industry partners, all of which are involved in various aspects of ACL reconstruction surgery. No individuals or groups have access to the dataset besides a sub-committee of the steering group which will have responsibility for investigating any data issues which may arise, such as data queries or potential outlier information. The NLR is overseen and managed by knee surgeons assisted by a manager who is responsible for the day-to-day operational workings and marketing. Although strongly supported by BASK, there are no formal connections. The NLR is a member of the BOA Quality Outcome group and the ISAKOS collaborative of international ACL registries. Since the launch, there has been a steady growth in interest and the number of patients

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added to the registry. Currently, outcome data has been collected on nearly 6500 patients and there are 135 registered surgeons inputting data. Collection of ‘big data’ is a powerful tool, provided that such data is interpreted, presented and incorporated in a responsible, professional way. Raw data can be misconstrued and misunderstood. Issues that arise need to be approached in a thoughtful and constructive way. For example, the apparent higher rates of ACL graft rupture starting to be reported in young female athletes in the Scandinavian registries is concerning, but may not have been noted without the collection of large datasets. The registries allow for the detection of trends, and allow us to then form hypotheses to test out why the differences might exist. Both insurance companies and private hospitals are starting to show an increased interest in registry data, and their interest may persuade private hospital group medical directors to encourage all surgeons to comply with this quality agenda. Similarly the clinical data related to the performance of fixation devices is of great interest for industry partners, and while they should never be allowed to influence treatment or surgical technique decisions, it is important that they encourage the responsible collection of data by surgeons using their products. Given the current recommendations of the BOA and the specialist societies about consultant outcome publication of National Joint Registry (NJR) data, NLR data for units will become increasingly

Outcome measures: National Ligament Registry 2015 Annual Report. important and is likely to be of particular interest to care commissioning groups (CCG)s. Challenges remain in the registry becoming established. In particular, patient and surgeon compliance remains an issue. A balance has to be struck between funding the labour intensive process of chasing patients to increase compliance (improving validity) and the overall effect on the result/message that emerges. Currently there is a national focus on the collection of patient-reported outcome measures, and this should be supported by all NHS Trusts. The best way to improve surgeon compliance is unclear. Mandating data input by surgeons who carry out ACL reconstruction in a similar way to the NJR is an option, but it typically comes with central backing and potential loss of (data) control. The NLR, however, aims to be true to the mission statement, “Developed by surgeons for the benefit of patients” - that is, surgeons who understand the data, control it. In time the NLR will produce far more data about our procedures than has been published to date, and this will give a meaningful reflection of our patient outcomes. Establishing a national ‘dataset’ will allow comparison of population demographics and outcomes with the established Scandinavian registries, and suggest trends in our own surgical practice. It will allow a better understanding of the management of the injuries associated with ACL rupture and allow us to monitor better the introduction of newer technical developments. However, potentially the biggest beneficiaries will be the patients. The website contains comprehensive information

about the injury, treatment options, and details of surgical options and guidelines on rehabilitation. The UK ‘surgeon map’ of NLR-registered surgeons will enable patients to view the workplace information of surgeons who record their ACL reconstruction data on the NLR. All surgeons are encouraged to feedback their views to the NLR, in order that we can develop something of which all UK surgeons can be proud. It is our responsibility to ensure that the systems that are developed are fit for purpose, not only for our patients, but also for our colleagues and those who will follow us.

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Sean O’Leary, Circle Reading Hospital, Berkshire, UK Chairman, NLR Steering Group (members: Tim Spalding, Fares Haddad, James Robinson, Mike McNicholas, William Hage)

sean.oleary1@btinternet.com

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B. Ledingham

CURRENT CONCEPTS

Current challenges in the surgery of rheumatoid arthritis

erendipity led me towards a career as a rheumatoid surgeon, surely one of the most rewarding and sometimes challenging areas in this huge and varied specialty of ours. Also, equally surely, a special interest now in decline for a number of reasons. As a registrar in Aberdeen in the 1980s, I operated on many patients whom I eventually inherited as a new consultant from my predecessor, John Gibson, in 1992; some still come to see me regularly. Having spent three years as a senior registrar (goodness, how I miss that tier of training now) in Bath at a tertiary referral centre for inflammatory joint disease, I felt wellprepared for my consultant post. The most extreme and medically resistant patients from the South West would end up at the Mineral Water Hospital (Royal National Hospital for Rheumatic Diseases), with their operations more often than not taking place at the Royal United Hospital. This provided a very useful grounding in rheumatoid surgery for any trainee. Over the years I have tried to make my rheumatoid clinic a place for seeing old friends and meeting new ones: I look on each consultation as a chance for us to catch up with each other and work out what, if any, procedure might be beneficial at this stage in their disease. The vast majority of the referrals are from my rheumatology colleagues, and I have been lucky enough to experience the benefits of sharing combined clinics with them for many years. The first consultation with the rheumatoid patient has to be a positive experience for them. Sometimes, the patient will only recently have been diagnosed with the condition. The diagnosis can carry some of the same stigmata in a patient’s mind as multiple sclerosis or Parkinson’s disease, with what they imagine must be an inexorable decline towards a wheelchair existence. Others will have had rheumatoid arthritis (RA) for a decade or two and will have just started to develop features which might benefit from an operation. Picking the right first operation to cement your relationship is crucial. Usually the choice is obvious to both surgeon and patient, but when

there are options, it is advisable to choose the one that is most likely to achieve the greatest relief of pain and increase in function with the smallest risk of complication. There are a few cast-iron procedures… hip arthroplasty, carpal tunnel decompression, wrist arthrodesis, forefoot arthroplasty and proximal interphalangeal joint fusions are all ones that Fig. 1. a and b) After reverse shoulder arthroplasty: bone can be banked upon. graft to glenoid. (Image courtesy of Mr Kapil Kumar). Once the patient, by now also your friend, has had of instances where a very specialised approach one or two successes, they will be able to accept is required, such as ankle replacement, reverse a procedure which doesn’t work out completely successfully with no hint of recrimination. They shoulder arthroplasty (Fig. 1) or surgery of the cervical spine, one can always find a colleague know that the condition of their skin, soft-tissues with those extra skills to oblige and, because the and bones, and the immunosuppressive nature of their treatment make them more prone to patients have been referred to them by their ‘own’ surgeon, the element of trust is very complications such as infection and delayed much greater than if they are referred by their healing. The rheumatoid patient is nearly always pos- rheumatologist to one orthopod for their hip, another for their feet, another for their hands itive, cheerful and knowledgeable about how and so on. treatment will affect them and whether they are In addition, anaesthetic expertise is vital in quite ready to have anything done. ‘Catastrodealing with these fragile patients. Venous phising’, a new term (to me) for patients whose conditions are having an extremely dispropor- access is sometimes very difficult; spinals too, may be troublesome, and neck mobility and tionate effect on their lives is unheard of. I have yet to hear a rheumatoid patient say “My life stability, and mouth opening can make intubajust isn’t worth living” or “Just cut it off, it’s no tion a challenge. A wider team approach is also essential, not use to me as it is”. Many continue to hold down simply by having combined clinics and expert jobs long after you might think they would have had to give up. They almost never ask for sup- anaesthetists, but also specialist physiotherapists, occupational therapists and nurses. port in getting a disability badge. The main breakthroughs in dealing with The rheumatoid surgeon, sadly, is a dying rheumatoid patients (and here we should breed due mainly to the superspecialisation that include the whole spectrum of inflammatory has developed in orthopaedics: I imagine that conditions) have been medical. I still remember mine will be the last generation of surgeons who feel willing and able to deal with most the old days where gold was one of the mainstays of treatment and large doses of steroids rheumatoid conditions. That is a real pity would be used much more than they are now. because most rheumatoid surgery is simple, In the early 1980s the use of methotrexate straightforward, and successful, the key chal(one of the original anti-cancer drugs) caused a lenges being deciding on the overall timing and revolution in the management of inflammatory ordering of these operations. In the 5% to 10%

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joint disease: very quickly the pattern of surgical treatment changed. More recently, the biological treatments have had the ability, on occasion, almost to stop the disease in its tracks. These beneficial changes have meant that certain operations need to be carried out much less frequently, some hardly at all. As a registrar and young consultant, I spent a significant amount of time doing synovectomies, mainly of the knees and wrists, repairing extensor tendons, replacing destroyed knuckles, referring unstable necks for stabilisation, and marvelling at the most horrific pairs of valgus knees, flexed hips and collapsed feet and ankles. In patients with ankylosing spondylitis it was a regular occurrence to see them curled over like a question mark, hardly able to see in front of their own feet. While these problems do still occur, they are rarities and not usually so severe and, with less steroid-induced osteoporosis and greater attention to bone preservation therapy, are easier to deal with. Even protrusio of the acetabulum seems to me less common, and the centrally dislocated and destroyed hip joint appears quite infrequently. I haven’t referred a patient for neck stabilisation in over two years. So, which operations work well, which not so well, and which are better avoided most of the time? The cemented hip is certainly to be recommended. It is predictable, good in poorer bone, and relatively easy to revise if and when it eventually fails. Knee (Fig. 2), shoulder and elbow (Fig. 3) arthroplasties are also extremely effective. Problems with pain and stiffness in the replaced rheumatoid knee are much less common than in our osteoarthritic patients. Complications after elbow arthroplasty are a little higher than in other replacements, with wound problems and neurapraxias of the ulnar nerve causing occasional but usually transient difficulties. Wrist (Fig. 4) and ankle arthroplasties are a little more controversial, the reason being that arthrodesis of these joints offers a very realistic chance of relieving pain and improving function. Nevertheless, in certain instances these replacements can offer better function, with the caveat that they will likely need to be revised later in life. Silastic knuckle arthroplasties should only be carried out to relieve pain as they do not tend to

Fig. 3. Ten-year films of Coonrad/Morrey total elbow arthroplasty (TEA) with some humeral bone resorption. Fig. 2. Patient-specific jigs may make bilateral total knee arthroplasty (TKA) safer. increase range of movement. They do, however give a very pleasing correction of the ulnar deviation and subluxed joints. Pyrocarbon joints should be viewed as experimental at the moment and followed up very carefully. In my opinion, the jury is still out. For the diminishing numbers of patients needing bilateral hip or knee replacement, I would recommend that the younger and fitter candidates be offered their procedures at the same sitting. Recovery from a hip arthroplasty when the contralateral hip is severely flexed or adducted is much more difficult: the same goes for flexion or valgus deformities of the knees. The use of patient-specific jigs can avoid the embolic risks of rodding the femur twice. In summary, rheumatoid surgery can be a challenge at times, complications can be devastating and there can be immense sadness when these courageous young patients succumb to their disease or the side-effects of treatment. Fortunately, these occasions are rare. The huge improvements in medical treatment have meant that the workload of surgeons dealing with rheumatoid patients has lessened. The satisfaction of helping the patient navigate the rocky waters of their condition, seeing them through procedure after procedure, getting to know them and their families as friends is such that I feel regret that the ‘rheumatoid surgeon’ will no longer be with us in just a few years.

Fig. 4. Wrist arthroplasty. (Thanks to Mr David Lawrie).

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Bill Ledingham, Consultant Orthopaedic Surgeon, Woodend Hospital & BMI Albyn Hospital, Aberdeen, UK bill.ledingham@btinternet.com

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C. E. Ackroyd

HISTORY

The history of the Victoria Cross and Harold Ackroyd VC, MC, MD, 1877-1917: Doctor, scientist and gentleman

he Victoria Cross is the highest award for bravery in the United Kingdom and Commonwealth. It was instituted in 1856 by Queen Victoria with a Royal Charter for conspicuous acts of bravery in the face of the enemy and could be awarded to all ranks. The harrowing reports of the Crimean War by the Times war correspondent, William Howard Russell, had led to general unease about the brutality of the war and the bravery of the fighting forces. The Queen and Prince Albert were instrumental in helping to design the medal which is a cross patteé with the crown of St Edward surmounted by a lion, and ‘FOR VALOR’ inscribed beneath. The obverse of the medal features the date of the event with the name of the recipient inscribed on the suspending bar. To date, 1363 awards have been made to 1359 individuals with three bars and the American Unknown Warrior. Awards have been made in every major conflict in the last 160 years. In the Crimea there were 111 awards, WWI 628, and WWII 182. The most recent was to Lance Corporal Joshua Leakey for action in Afghanistan in 2015, the 20th

formed Institute for the study of Animal Nutrition, Department of Agriculture and worked with Sir Frederick Gowland Hopkins, the first Professor of Biochemistry. He carried out his animal research experiments in the garden of his house in Kneesworth Road, Royston and would travel to Cambridge every day by train or on his motorcycle. He published at least six papers on purine metabolism in the Biochemical Journal, the last in 1916 with Sir Frederick.

award since WWII and the eighth in the recent Afghanistan war. There are now ten living VC holders including four holders of the separate awards for Australia and New Zealand, which were instituted in 1991. The medals are cast from the cascabal of two cannons of Chinese origin, probably captured from the Russians in the Crimea which are currently in the Firepower Museum at the Royal Artillery Barracks, Woolwich, London. The firm Hancocks have cast all the medals and there is some 10 Kg-m of the metal left, enough for a further 70 to 80 medals. One hundred years ago on 4 August 1914, Britain declared war on Germany, drawing the British Empire into one of the greatest conflicts of the 20th century. At the start of the war, Britain had a professional army of 80 000 men, facing a German army of over 1 million men. After initial reverses, Britain and France halted the German advance at the Battle of the Marne on 6 September and pushed the German forces back to eastern France and Belgium, to the stalemate that was to form the Western Front and the long and vicious war of attrition which resulted in the

Photo 1. Portrait of Harold Ackroyd. (By Bristol artist Jerry Hicks). loss of over 1 million men. and countless more severely injured both physically and mentally. Field Marshal Lord Kitchener, a veteran of the Boer War, realised by mid-September 1914 that the war was not going to be over quickly and so started the massive recruitment campaign to form his New Model Army. Harold Ackroyd was born in July 1877 in Southport, and was a pupil at a local preparatory school before attending Shrewsbury School. From there he gained admission to Gonville and Caius College Cambridge to study medicine. After his BA degree he spent a further year at Cambridge working on biochemical research. He then went on to Guy’s Hospital, qualifying in 1904. After resident jobs at Guy’s, Birmingham General and Liverpool Northern Hospitals, he returned to Cambridge and we think he may have taken a post at the Strangeways Research Hospital where he met his future wife, Mabel Robina Smythe, who was the matron. They married on 1 August 1908 at All Saints Church, Southport, and had three children, Ursula, Stephen and Anthony. Harold was awarded a BMA research scholarship in 1908 for three years and immersed himself in academic work, first in Professor W.E. Dixon’s laboratory at the Downing Street site and then in the newly

In early 1915 recruitment to the army had reached fever pitch. Harold was now 37 years old and although he had no recent acute accident or medical experience he decided to join up, and after initial training he was attached as Medical Officer to the 6th Battalion Royal Berkshire regiment, part of the 53rd Infantry Brigade in the 18th Division, and they sailed for France in July. His commission papers show that as a Temporary Surgeon Lieutenant he was paid 24 shillings a day (£1.20). The regiment was involved in numerous actions in 1915, and he

Photo 2. Harold’s grave stone at Birr Cross Roads Cemetery, Ypres, Belgium.

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Harold returned to the Battalion in December and they moved up to Ypres to prepare for the third battle (Passchendaele) in July 1917. On 31 July and 1 August, in the action to secure Glencorse Wood, Harold repeatedly rescued injured men from no-man’s land and at the end of the action there were 23 separate recommendations for bravery which resulted in the award of the Victoria Cross. The history of the 18th Division records, In all that hellish turmoil, there had been one quiet figure, most heroic, most wonderful of all. Doctor Ackroyd rose to the supreme heights that day. He seemed to be everywhere; he tended and bandaged scores of men, for to him fell the rush of cases. No wounded man was treated hurriedly or unskilfully. Ackroyd worked as stoically as if he were in the quiet of an operating theatre. Complete absorption in his work was probably his secret.

Photo 3. HRH King George V bestows the medals on Mabel and son Stephen on 26 September 1917. was promoted to Temporary Surgeon Captain in February 1916. It was at the battle of Delville Wood in July 1916, early in the Somme campaign, that Harold showed true courage, treating over 1000 casualties, British, South African and German, and received eleven recommendations for bravery, actions for which he was awarded the Military Cross. The history of the 18th Division records that

insisted that he take six weeks leave but in a letter to his brother on 4 September, Harold said, “I am quite well and fit to return to duty” after just two weeks and regarded them as “an awful lot of old fossils”!

Sadly, ten days later on 11 August, Harold was attending to casualties in a shell hole in Jargon trench in no-man’s land when he was shot in the head by a German sniper and died instantly. He was buried at Birr Cross Roads cemetery on the Menin Road near Ypres, which was designed by Sir Edwin Lutyens. The award was gazetted on 6 September and at an investiture outside Buckingham Palace on 26 September, King George V bestowed the medals on his widow Mabel and their eldest son Stephen, aged five years. Harold’s death had a devastating effect on Mabel and the family. She remained in mourning for the rest of her life.

Capt. Ackroyd, the Medical Officer of the Berks, was a heroic figure during those two days. The fighting was so confused and the wood so hard to search that the difficulty of evacuating the wounded seemed unconquerable. The bespectacled and stooping Capt. Ackroyd, a Cambridge Don before he joined the Army, was so cool, purposeful and methodical, that he cleared the whole wood of wounded, including German. Harold was probably exhausted after being under continuous bombardment for some days, and was injured in some way. He was sent home on sick leave in August but within two weeks he had recovered and was demanding to return to the Battalion. The medical board

Photo 4. Harold’s medals: VC, MC, 14/15 Star, War Medal, Victory Medal.

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Photo 5. Neil McKendrick and Christopher Ackroyd signing the scholarship deed in the Masters Lodge, Gonville and Caius College Cambridge, 17 November 2003.

The medal set was first inherited by Harold’s eldest son Stephen on Mabel’s death in 1947, and then in 1963 by his second son Anthony. After his death in 1988, the medals were inherited by Harold’s grandson Christopher, a Caian and an Orthopaedic Surgeon in Bristol. In 1993 Christopher decided to take possession of the medals which had been on loan to the RAMC since the Centenary Exhibition at Marlborough House in 1956. In fact the medals were kept securely in military vaults in Aldershot, and replicas were displayed in the VC room at RAMC headquarters, Milbank. The medals were displayed in his consulting rooms in Bristol and were viewed by many patients. In 2003, Christopher was considering the future, as the medals had risen considerably in value. After much debate within the family he finally decided to sell the medal set to an anonymous purchaser and donate the proceeds to Gonville and Caius College to fund a four year medical scholarship and an annual medical lecture. Twelve scholars have now been elected, the most recent of whom is Timothy Venkatesan, and there have been twelve

Photo 6. The Princess Royal being presented with Lilies of the Valley by Mia Pearlman, Harold’s great great granddaughter at the opening of the Lord Ashcroft Gallery, Imperial War Museum, 10 November 2010.

lectures given by distinguished medical scientists which have included six Nobel Prize winners. The final piece of the story is the fate of the medals. In 2006 Lord Ashcroft published his book, Victoria Cross Heroes, and it was revealed that Harold’s medals were part of the Lord Ashcroft Trust collection of over 242 VCs and GCs, and would be exhibited in a specially-built gallery at the Imperial War Museum. On 10 November 2010 the Princess Royal opened the Lord Ashcroft Gallery, and lilies of the valley were presented to her by Harold’s great great granddaughter Mia Pearlman, aged six years. The hope is that the scholarship will continue in perpetuity and Harold’s story will be a lasting example and legacy to the medical students of the future. “For most conspicuous bravery. During recent operations Captain Ackroyd displayed the greatest gallantry and devotion to duty. Utterly regardless of danger, he worked continuously for many hours up and down

and in front of the line tending the wounded and saving the lives of officers and men. In doing so he had to move across the open under heavy machine-gun, rifle and shell fire. On another occasion he went some way in front of our advanced line and brought in a wounded man under continuous sniping and machine-gun fire. His heroism was the means of saving many lives, and provided a magnificent example of courage, cheerfulness and determination to the fighting men in whose midst he was carrying out his splendid work. This gallant officer has since been killed in action.” London Gazette, 6 September 1917.

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details

Christopher E. Ackroyd, Bristol, UK ackroydchristopher@yahoo.co.uk

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L. Wicks

NOTES FROM THE ROAD

Bone setting in the land of Prester John

ast November, two visits were undertaken to Ethiopia, both funded by The Bone & Joint Journal, which had earlier provided free online subscriptions for all orthopaedic residents in the country. The first visit was to Gondar by a team from The University Hospital of Leicester led by Laurence Wicks. The second was to Addis Ababa, led by Tony Clayson, and continued the longstanding relationship between the Black Lion Hospital and World Orthopaedic Concern, which also supports the Leicester/Gondar link. In addition, Chris Kershaw from Leicester managed to visit both centres. Here are their stories.

Gondar Laurence Wicks (Orthopaedic Registrar, Leicester) Gondar is the ancient capital of Ethiopia, situated approximately 700 kilometres north-west of Addis, amongst the mountains of the Amhara region. The University of Gondar, first established as the Public Health College in 1954, is the oldest medical school in Ethiopia. The 400-bed University of Gondar Hospital is the referral centre for four district hospitals in the area. Its specialities include paediatrics, surgery, gynaecology, psychiatry, HIV care and an outpatient clinic. Within its 400 staff, it employs 50 doctors, 150 nursing staff, three pharmacists, 90 care staff and 25 laboratory scientists. They serve a population of four million across the region. As a university hospital, it also plays an important role in teaching medical and nursing students. As with the rest of Ethiopia, and indeed throughout Africa, trauma is a major part of the workload for the surgical department. Most orthopaedic inpatients are either on skeletal traction with femoral fractures, or have severe open tibial fractures which require weeks of treatment. Many of the open fractures are complex and would be difficult to manage anywhere in the world. In Gondar, management is not helped by limited resources, which include a lack of theatre time and expertise in bone and soft tissue reconstruction. Currently, a patient with a severe open fracture is likely to need a

prolonged hospital stay and suffer long-term disability. There is a single dedicated orthopaedic list each Friday. This is decided on the Thursday ward round, mainly determined by which patients have waited the longest. Priority is given to those awaiting SIGN nails. Patients with femoral fractures are treated in traction or by SIGN nailing, which is typically two weeks after admission due to the lack of operating lists.

uncommon to see young adults limping or hobbling with a crutch, the tell-tale sign of a poorly-treated leg injury. The orthopods amongst us often attempted a spot diagnosis over a cup of coffee, as we people-watched and gazed at Ethiopian life going by. In the whole of Ethiopia there are very few orthopaedic surgeons, most of them in the capital Addis Ababa. There are two newlyappointed orthopaedic surgeons in Bahir Dar,

It would be ideal to have at least one other orthopaedic operating list earlier in the week, especially for open fractures which would benefit from more regular debridement. A health partnership has existed between Gondar and Leicester for almost 20 years. This was my third trip to Ethiopia, but my first with a team of colleagues from the UK. This was only possible through the generous support of The Bone & Joint Journal. It is my hope that a strong orthopaedic link will continue to develop with Gondar, supported by World Orthopaedic Concern UK and the Leicester/Gondar Link. My colleagues on this trip have each provided their own reflections, which I share with you in the following paragraphs.

the capital of the Amhara province. In Gondar there is one general surgeon with orthopaedic training, Dr Momhammed Kedir, who has facilities to perform a limited repertoire of stabilisation procedures on a weekly basis. There are currently three doctors, sponsored by Gondar University, at various stages of orthopaedic training at the Black Lion hospital in Addis. We aim to support them on their return to Gondar, in the hope that over time, orthopaedic services can be developed to minimise disability and protect livelihoods. Emergency trauma cases in Gondar are managed by general surgery residents. Open fractures undergo an initial debridement on arrival, with stabilisation by old AO external fixators that have been used repeatedly over the last thirty years. Therefore, our group focussed almost exclusively on open fractures. We were prepared for this thanks to Laurence's previous scouting trips. A plastic surgeon in tandem with an orthopaedic surgeon certainly came in handy. The recent report of the Lancet Commission on surgical provision for the poor worldwide came as real encouragement to us. In this report, the ability to manage open fractures is considered a vital, or bellwether, procedure. By improving the management of open tibial fractures through teaching and hands-on training, we believe that the skills learnt are transferable to the management of other orthopaedic conditions and injuries.

Alwyn Abraham (Orthopaedic Surgeon, Leicester) The challenge of access to health care for most Ethiopians was evident during our visit. With about 80% of the population engaged in rural agriculture, for some even getting to the nearest road to hitch a ride in an overcrowded lorry was a day’s journey by foot. That would get them as far as the district hospital where they would see a GP-type doctor. Given the multitude of orthopaedic injuries, it was therefore unsurprising that most injuries are taken to the nearest wegesha (bone setter), sometimes with disastrous results. During our two-week stay in Gondar we only ever saw open injuries or femoral fractures. Where were the common closed injuries? Where were the wrist, ankle and knee injuries which are common worldwide? The only supracondylar fractures we heard of in children were late presentations, where the wegesha had bound the limb up so tightly that gangrene had resulted, with amputation the only recourse. It wasn't

Sunil Thomas (Plastic Surgeon, Birmingham) Gondar is a University Hospital with all the infrastructure already in place. There is a lot of new construction (though temporarily on hold) which has the potential for growth. It provides teaching and skill development for nursing and

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for medical trainees and surgical practitioners who are not qualified doctors but are based in rural areas to provide emergency surgery for the local population, a concept very pertinent to rural Africa. The principle of early wound cover is important as it decreases the risk of deeper infection and saves money on dressings. Even if 50% of a split skin graft takes, it reduces the wound by half and acts as a biological dressing to facilitate healing. Performing local flaps on known perforators was a new technique for many of the juniors, and the opportunity to train surgical residents, who were hungry for new skills, was gratifying (Figs 1 and 2). The local doctors are skilled in taking skin grafts but had to re-use the Watson knife blades which became blunt over time. The donation of these and an autoclavable ‘metal mesher’, would be helpful. Donor site nonadherent dressings, such as alginates (kaltostast and local anaesthetic) would help improve patient care and pain relief. Another alternative is Mefix dressing rolls, which can be autoclaved and applied directly to donor sites and left for two weeks. It is often simple equipment that would make the biggest difference, such as a new trolley to wheel patients into theatre to have their wounds grafted, where transfer was not hitherto possible due to skeletal traction on fixed beds. Braun frames to elevate injured legs would also be helpful. More high-tech equipment, such as topical negative pressure (TNP or VAC) dressings could dramatically improve the management of significant wounds; perhaps this is something to strive towards in the future. Meanwhile, the local doctors are to be com plimented in their innovation with limited resources, such as using inflated gloves to prevent pressure sores on heels. Along these lines, non-adherent dressings could be made locally with thin muslin cloth impregnated with acriflavine emulsion and autoclaved locally in the ‘little sister’ in theatres. Honey is also readily

Fig. 2. Flap coverage for the same patient.

Fig. 3. Dean Birch teaching casting techniques.

available. Its many benefits in wound care are well known in the UK and I encouraged the surgeons to consider using locally-sourced honey on their patients’ wounds. Other effective practical changes that are feasible include introducing measures to ensure regular washing of wounds and soiled feet following RTA. A hand-held water jet, like a smaller shower head in many of the local toilets, would be useful in cleaning wounds and burns. Relatives are able to take the burden off the nursing staff, doing this with simple soap and water. Indeed, if the senior nursing staff were relieved of many daily tasks, they could take on roles equivalent to orthopaedic practitioners and tissue viability nurse specialists. I benefitted immensely from seeing the positive ethos and camaraderie among all levels of staff, their smiles (despite less than ideal circumstances) and their generosity in welcoming us and sharing with them. I missed not being able to communicate directly with the patients, but the interns were very helpful and proactive to facilitate communication.

plaster of Paris (POP); this was heavy for the patient and difficult to cut off. If it was a slab it was held in place by a lint bandage. The patient would be sent on their way, which in some cases could be several hundred kilometres. Often patients are treated nearer home by the local wegesha (bone setter), with mixed results. The reaction I received from the colleagues at Gondar was wonderful. They were so willing to learn and take on board my techniques. We came armed with materials such as stockinette, better quality POP and undercast padding, and crepe bandages, which made casts much easier to apply. Sadly it appears difficult to source materials of this standard locally. Every cast I applied would be attended by quite a crowd, all observing, helping and listening intently (Fig. 3). I’ve never had so many holders and assistants for both upper and lower limb casts! Each casting became an event, with Q&As during and after. Their enthusiasm and interest in what this ‘white wegesha’ was doing was heart-warming and rewarding. When I applied casts on the ward, a crowd of onlookers would appear: patients seemed much happier with their lighter, better functioning casts. A few learned words of Amharic used while the cast was being applied always impressed the patients. After just a couple of days working between the minor OR and wards, I had a magic moment. I arrived in the minor OR for that day’s adventure and on a trolley sat a gentleman relaxing and displaying what appeared to be one of my casts. It had been applied overnight by one of

Dean Birch (Orthopaedic Practitioner, Leicester)

Fig. 1. IIIB open tibia, a common and difficult problem.

My role was to impart some of my casting knowledge and techniques to the local staff, who greeted me with great enthusiasm. The application of plaster casts is primarily carried out by junior doctors (residents and interns) who have little formal training. As a result, the casts often leave a lot to be desired. Before my visit, the casts at Gondar consisted of cotton wool as undercast padding stretched to fit the limb, then 12 to 16 layers of

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Fig. 4. Doctor Minarg with his cast. the doctors who had been closely assisting me over the previous days (Fig. 4). It was an extremely rewarding to see that over a short time the basic techniques and skills had been assimilated and put into practice. Just think what we could do with more time and teaching. On reflection, this is my overwhelming feeling of the trip. In the UK, because the role of the orthopaedic practitioner is recognised, by attainment of the British Casting Certificate (BCC) at Stanmore, and high-quality casting care is expected, we only realise how blessed we are when we have the chance to visit a country such as Ethiopia. With simple teaching and training, so much can be achieved. I have remained in contact with some of the colleagues at Gondar by email, to offer any assistance that I can give, and a few have received the digital copy of the BCC casting guide for reference. I had such a positive response from the staff that I sincerely hope that this collaboration can be continued in the future. Amsegenolehu (thank you), from ‘Mr Dean – the POP Man’. Christopher Kershaw (Orthopaedic surgeon, Leicester) My plan was to spend two weeks, just after early retirement, assessing my potential usefulness in the developing world, the inspiration for this being a pep talk from a younger colleague telling me, “I’ve been there twice before and we can make a difference”. My first concern after arriving in Gondar in the late afternoon, after 36 hours awake, was being told that we were sightseeing in the Simian mountains the next day (only day off, so might as well be day one), but we had to get up

at 5.30am to make it (thanks to the same younger colleague who got me out here in the first place!). The second concern came soon after… the driver arrived an hour and a half late but proceeded to make up time by driving at speeds of over 110 km/hr on the wrong side of poor roads until we reached our destination. The third concern: 25% of the group were already too ill to enjoy the trip. From here on, things got better. The scenery in the Simians is awe-inspiring (Fig. 5), a cross between the Drakensbergs and Monument Valley with only the thin air stopping one from running around chasing the Simian Ibex (4300 metres is quite high). Northern Ethiopia has some amazing places to visit and Axum, Lallibela and Lake Tana offer such diversity of sights and experiences that they will feature on my bucket list. Monday morning at Gondar Hospital reminds one of the dignity with which so many in the world bear suffering and disease; the pathology that we in the developed world have almost forgotten and the enormous task that confronts surgeons from Ethiopia and afar. Chronic osteomyelitis (Fig. 6), neglected clubfeet, open fractures still open months later, amputations for neglected sarcoma, infection or trauma, rampant rickets and high hip dislocations make one realise how so much preventable pain and disability exists. The ward rounds and discussions with surgical residents showed a keenness and intelligence that gives one hope that in a generation it will be better (and that is not long for a country still mainly employed in practising subsistence agriculture, and feudal until 60 years ago). My main time was however spent in Addis Ababa, meeting orthopaedic surgeons in the

Fig. 5. Dean and others feeling the strain in the Simian Mountains. Black Lion Hospital and CURE Hospital. I quickly developed admiration for consultants and trainees whose surgery has to cope with a ‘make do’ attitude to equipment, and perform complex fixation without the benefit of radiographs, never mind an image intensifier. I appreciated the high-quality training and leadership from Dr Geletaw, the young Head of Orthopaedics at the Black Lion Hospital. Eager trainees abound, but I worry if they will have the facilities to achieve their potential so that they can reach the vast under-treated population. In particular, I met four of the six paediatric orthopaedic surgeons in Ethiopia who treat some of its 25 million children. Particular thanks for the kindness and hospitality of Tim Nunn at CURE, and to Dr Teddy and Dr Mesfin. Here you see how good administration, clean, well-run wards, skilled anaesthetists and the facilities and equipment that enable surgeons to undertake definitive, safe and effective surgery brings visible health benefits. What can we do? Black Lion needs an image intensifier to help orthopaedic surgeons improve. Guesswork, even skilled, is not good for the patient or surgeon. A consistent flow of basic fracture kit and training in its use would be life-changing. There is a need to keep reinforcing talipes management (Fig. 7), develop better plastering techniques and greater understanding of closed fracture management, so that teaching at many levels is good. There are complex cases of every shape and form, and

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Fig. 6. Chris Kershaw teaching Dr. Minarg before operating on a child with hip sepsis. they appreciate skilled hands and enthusiastic encouragement. I learned a lot! As a cautionary note to finish, the main ring road in Addis has multiple lanes in each direction. Always drive in the middle lane to avoid the four-foot wide and eight-foot deep uncovered drain holes that pepper the inside and outside lanes.

Addis Ababa Tony Clayson, (Orthopaedic Surgeon, Wrightington) Having been a member of WOC for some years but without the opportunity of working in a developing country for professional and family reasons, I was enthused when in early 2015 I learnt that WOC was looking for a surgeon with an interest in pelvic and acetabular surgery to visit the Black Lion Hospital in Addis Ababa. I had long wished to contribute to overseas development and training and, following conversations with Rick Gardner at The CURE Hospital in Addis, this opportunity seemed perfect. Subsequent conversations with David Jones highlighted the wishes for WOC to enhance its links with Ethiopia, and my two-week visit was made possible through the generous support of The Bone & Joint Journal. The aim was to establish a link with Dr Geletaw, Head of Orthopaedics, who had recently started performing pelvic surgery, and to assess how WOC could work with other groups to help develop orthopaedic and trauma services.

I was uncertain what to expect on my first walk to the Black Lion Hospital on Monday morning through congested traffic and construction everywhere. Following an introduction by Rick Gardner at the daily trauma meeting, I joined a ward round where we found ten femoral fractures awaiting fixation, plus many other trauma cases! There has been a massive increase in trauma as Ethiopia is investing heavily in roads and construction without established trauma services, and with very few orthopaedic surgeons. The government response was to increase significantly the number of orthopaedic residents at the Black Lion to 77, although there are only 12 consultants in orthopaedics of whom four or five regularly attend the daily trauma meetings and theatre. Consequently, there is an eager group of trainees who are clearly well-read but struggling to develop their surgical skills due to a shortage of senior support, limitations of theatre space and no image intensifier. That being said, as Chris Kershaw has mentioned, Dr Geletaw is an enthusiastic and gifted young surgeon who has the determination to lead the service and benefitted greatly from the senior support and advice I gave him at our one-toone meetings. He has also recently been joined by Dr Sami, an Ethiopian surgeon who has returned from a fellowship in Seattle and is keen to develop the training programme further. I quickly learned that in a two-week visit my time would be best spent supporting the residents in theatre where I scrubbed with them

Fig. 7. Ponseti clinic at The Black Lion Hospital.

Fig. 8. Colleagues from Leicester and Wrightington establish links with Black Lion Hospital Orthopaedic training programme. From left: Laurence Wicks, Tony Clayson, Dr Geletaw, Chris Kershaw. every day, adopting a ‘first assistant’ role. I used these interactions as an opportunity to reinforce the principles of fracture care, focussing on preservation of blood supply, limited

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exposure and the handling of soft-tissues. I had decided that I would not personally carry out any operations, but would prefer to assist developing colleagues and trainees. I was particularly pleased to assist Dr Geletaw undertake an extremely complex acetabular fixation early in my visit and guide him through the post-operative care afterwards. We both found this a rewarding experience as mentor and mentee. The daily trauma meetings attended by all residents and one or two Black Lion consultants plus myself were also a great opportunity to discuss the management of cases. Every Thursday is all-day teaching, which I led on both of the weeks I was there, delivering practical sessions on acute management of pelvic trauma and multiply-injured patients with enthusiastic audience participation! I had heard from conversations during the first week that for the first time the Ethiopian Health Ministry’s Healthcare Service Transformation Plan, published in 2015, identified the management of trauma as a healthcare priority and as part of its strategy is establishing a new Orthopaedic and Trauma Unit at Hawassa, Southern Ethiopia. I therefore visited Hawassa Referral Hospital and University over the middle weekend of my visit and met the Chief of Surgery, Dr Malede, who showed me around his hospital. The two senior orthopaedic residents from the Black Lion, Dr Ephrem and Dr Mamo, are starting in Hawassa in January 2016. Having established good relationships with both, and with Dr Malede, I believe that the continued

support and mentorship from WOC visitors will greatly help the further development of trauma services in Ethiopia. By the end of my visit I was even more enthused about the extremely positive role that visits from consultants with experience in trauma can play in Ethiopia’s further development. Faced with the rapidly increasing impact of trauma victims on Ethiopian society, the Health Ministry has a strategy for increasing the number of orthopaedic surgeons throughout the country, although the current consultants in Addis are struggling to deliver the training required. I therefore feel that WOC is ideally placed to support this process, and hopefully identify trainers who want to help Ethiopia develop a sustainable solution. I am not naïve enough to think this will be a quick process but, although Ethiopia presents significant challenges, there are also fantastic opportunities. Since returning home I have learnt more about other organisations such as Australian Doctors for Africa (ADFA), the AO Alliance Foundation and others who together wish to support the development of trauma and orthopaedic services in Ethiopia. I hope the visits of myself and colleagues from Leicester, generously funded by BJJ and supported by WOC, are the beginning of a regular, coordinated approach to future visits. I believe that with regular input from experienced overseas mentors, our young orthopaedic consultant colleagues in Ethiopia will develop the trauma and orthopaedic service their country requires.

Acknowledgment We would like to thank The Bone & Joint Journal for their financial support of this trip. We also thank World Orthopaedic Concern UK, the Leicester-Gondar Link, University Hospitals of Leicester and University Hospital of Birmingham NHS trusts for their kind support. The staff at Gondar University Hospital, the Black Lion Hospital and CURE opened their doors to us with warmth and kindness, for which we are truly grateful. Editor’s notes Prester John was a legendary Christian ruler with a kingdom that occupied much of East Africa, including Ethiopia. According to the 12th century Bishop Otto of Freising, he was descended from one of the three Magi associated with the Nativity. The legend was established at the time of the first crusades, when it was hoped that the Christian kingdom of Prester John would support the recapture of Jerusalem from the Saracens. World Orthopedic Concern UK welcomes consultants to participate in the link with the Black Lion Hospital. Please contact Deepa Bose (secretary@wocuk.org) for further information. A uthor

details

Laurence Wicks, University Hospitals of Leicester, UK wickslaurence@yahoo.co.uk

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NOTES FROM THE ROAD

N. M. Eisenstein

Heterotopic ossification – a model for interdisciplinary working: a report on the Heterotopic Ossification Mini-Symposium, Institute Of Translational Medicine, Birmingham, 27 October 2015 respected specialist in advanced spectroscopic analysis of wounds and has published extensively in this field, particularly on the use of Raman spectroscopy. She is a senior researcher at the Naval Medical Research Center, Department of Regenerative Medicine, and the Department of Surgery, Uniformed Services University of Health Science (Maryland, USA). Her team are working towards using non-invasive spectroscopic techniques in order to provide objective and accurate information to guide surgeons’ decision-making in real time. Raman spectroscopy could be used to identify very early changes in tissue composition that portend the development of HO at later time points, for example. In addition to this predictive capability, characteristic changes in wound spectra can provide a wealth of information including maturity of mineralisation, degree of carbonation of the hydroxyapatite, and mineral content of the tissue. All of these parameters can be gained in a short period of time using ‘semi-ruggedised’ spectroscopy equipment that can fit onto a standard nursing trolley. Data gained in this way can diagnose early HO with up to 90% specificity and 90% sensitivity, making it a potentially game-changing technology which allows surgeons to excise mineralising tissue with confidence at an earlier stage than would otherwise be possible. Dr Chris Howle: Negative contrast spectroscopy

Introduction Heterotopic ossification (HO) is rapidly becoming a hot topic in orthopaedic research due to its emergence as a common and disabling consequence of major combat trauma. While it may be seen less frequently in civilian practice, HO is no less troubling for those patients who develop it after arthroplasty, burns and central nervous system injury inter alia. Our current state of understanding of this condition remains far less developed than in many other orthopaedic diseases, and this too contributes to its allure for researchers. Given the complexity of the problem and lack of knowledge in this area, it has become clear that the best way to make progress is by bringing together experts from a wide variety of fields in order to share understanding and collaborate on future projects. This was the purpose of a multidisciplinary meeting of academics and clinicians that took place on 27 October 2015 at the Institute of Translational Medicine, Birmingham. The aim of this report is to provide an insight into the state of the art of research in heterotopic ossification, and to invite any interested parties to contribute to future meetings on this topic. Dr Nicole Crane: Raman spectroscopy in heterotopic ossification diagnosis Dr Crane was our guest speaker and had flown in from the United States very early on the morning of the meeting. She is an internationally

Dr Chris Howle is a specialist optical spectroscopist, and was one of the senior researchers from the Defence Science and Technology Laboratory in attendance. Dr Howle and his team are developing a novel hyperspectral imaging technology for stand-off chemical detection, in partnership with industry that operates in parts of the infra-red band of the electromagnetic spectrum that have previously been inaccessible for this purpose. While this technology is in a more embryonic stage than that used by Dr Crane and her colleagues, this work has the potential to locate the characteristic chemical changes across a wound that tend to predict HO formation and other wound states. The utility of this system for noninvasive imaging of wounds is now being investigated in concert with the Medical Sciences Programme at the Defence Science and Technology Laboratory, Salisbury. Surgeon Captain Mark Midwinter: Strategy and direction of the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre As its deputy director, Surgeon Captain Midwinter provided an overview of the research strategy and active projects currently being supported by the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC). The NIHR SRMRC currently supports a large number of research projects related to combat and civilian trauma with a particular focus on wounds and healing. Through

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working closely with the Birmingham Human Biomaterials Resource Centre, the logistical and technical expertise of the organisation has been instrumental in the collection and tissue-banking of samples of HO excised from British military personnel after high-energy combat trauma. This precious resource is being analysed as part of the author’s PhD research project.

Major Neil Eisenstein: A novel approach to heterotopic ossification prevention and treatment Major Eisenstein (the author of this report) is a military trauma and orthopaedics trainee currently undertaking a PhD at the University of Birmingham under the supervision of Professor Liam Grover and Surgeon Captain Sarah Stapley. He presented the preliminary results of his doctoral research, which is focussed on understanding the physicochemical properties of HO and the development of a novel means of preventing and treating it. Micro computed-tomography, mapped Raman spectroscopy, electron microscopy, and micro X-ray fluoroscopy results have provided intriguing insights into HO’s chemical make up. In vitro results have demonstrated proof of concept that it is possible to use a simple agent to dissolve hydroxyapatite, the hard mineral component of HO, at physiological pH range. Work on the development of a gel-based delivery vehicle for this agent was also presented.

Dr Yang Liu: Tissue and computational modelling of heterotopic ossification Loughborough University was represented at the meeting by Dr Yang Liu, Dr Owen Davies, and Begum Zeybek. Dr Liu presented work from all of the team members. One of the key areas where the team are making progress is in the development and characterisation of a tissue model of HO, something that currently does not exist. Using traumatised C2C12 mouse muscle cells grown in tethered culture, they have shown that it is possible to isolate a population of precursor cells with a significant osteogenic potential. Through systematic investigation of the effect of different pro- and anti-osteogenic cytokines on this system, they are able to determine the relative contributions of each, and even their interactions. In this way, the team aims to apply the tissue model as a tool to aid further mechanistic investigation, and then to prevent ossification by decoupling a key relationship in a temporally- and spatially-controlled manner, thus suggesting a future therapeutic target. Begum Zeybek’s finite element analysis work was also presented. She is using computer modelling to identify how the mechanical environment of wounds and post-amputation residua may contribute to the development of HO. In particular, her work will attempt to establish the mechanical effect of topical negative pressure therapy at various stages of wound healing, and with the corresponding change of tissue mechanics. The influence of such negative pressure dressings on the development of HO remains controversial and challenging to establish experimentally given their near-ubiquitous use on wounds caused by major combat trauma. This computational approach may well provide some much-needed insight, particularly when the model has been refined using CT data from those who developed HO.

Dr Richard Williams: Physicochemical analytical techniques in mineralised tissue As a physicist with expertise in imaging and physicochemical analysis of calcium phosphates and mineralised tissue, Dr Williams demonstrated the relevant capabilities currently available at the University of Birmingham.

Using a state-of-the-art mapped Raman spectroscopy system he provided novel data on the relationship between calcium phosphate phases and collagen in combat-related HO samples. The recent acquisition of a micro X-ray fluoroscopy system by the University has also opened up the ability to non-invasively map individual elements on a micron scale in biological samples. This has already provided insights into the mechanism of mineralisation in HO. Given that trauma is known to have a profound effect on the chemical environment of cells, tissues, and organs, these chemical analytical techniques will play a significant role in characterising these changes with ever greater spatial resolution.

Clinical input The meeting provided a rare forum for dialogue between clinicians and basic scientists, and enabled insights from both sides to inform the other. Between them, Wing Commander Demetrius Evriviades, Surgeon Captain Mark Midwinter, Group Captain Ian Sergeant, and Surgeon Captain Rory Rickard shared their wealth of operative experience of dealing with post-traumatic HO, and helped to inform what direction research should take to fulfil unmet clinical needs. In this one meeting, we brought together orthopaedic surgeons, general surgeons, a plastic surgeon, spectroscopists, biologists, a physicist and a mathematician; representing both military and civilian institutions from across the country and including the United States. Significant collaborations have been formed as a consequence of bringing together such a varied group of people and it is our assertion that, to make further progress, we need to involve even more people with an extended array of expertise. To that end we shall be organising another HO research meeting in 2016, and anyone who is interested in attending and contributing should contact the author for further details. List of attendees: •• •• •• •• •• •• •• •• •• •• •• •• •• ••

Dr Nicole Crane - Naval Health Research Centre, San Diego, USA (Presented: Raman spectroscopy and HO / wound infection) Surgeon Captain Mark Midwinter - RCDM / NIHR SRMRC (Presented: NIHR SRMRC) Dr Beryl Oppenheim - NIHR SRMRC Dr Abi Spear - DSTL Dr Chris Howle - DSTL (Presented: Negative contrast imaging) Sara Macildowie - DSTL Dr Yang Liu - Loughborough University (Presented: Tissue model of HO and finite element analysis of HO wounds) Dr Owen Davies - Loughborough University Begum Zeybek - Loughborough University Major Neil Eisenstein - RCDM / University of Birmingham (Presented: PhD work on novel HO treatment) Dr Richard Williams - University of Birmingham (Presented: MicroXRF and Raman spectroscopy capabilities) Wing Commander Demetrius Evriviades - RCDM / QEHB Surgeon Captain Rory Rickard - RCDM / Derriford Hospital Group Captain Ian Sergeant - RCDM / QEHB

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Neil Eisenstein, National Institute for Health Research, Queen Elizabeth Hospital, Birmingham, UK eisenstein@doctors.org.uk

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D. Cundall-Curry

NOTES FROM THE ROAD

Report from the International Combined Meeting of the British Hip Society and Societa Italiana Dell’Anca, Milan Italy, November 2015

n Milan, all roads lead to or from the Duomo. Just a few miles from this monument of architectural achievement, human endeavour and faith, sits the Marriott Conference centre, the epicentre for the first meeting of its kind: an international collaboration of two national hip societies, for two days of unparalleled presentations and debate exploring current and future practice and research. In November 2015 delegates from around the globe travelled to Milan for the Combined Meeting of the British Hip Society and Societa Italiana Dell’Anca, a collaboration formed through the hard work and organisation of the congress chairmen, President Elect, Professor Fares Haddad and Presidente Luigi Zagra. The capital city of the Lombardy Region in Italy provided the perfect backdrop for the conference with six instructional courses, six cross-fires on hot topics, seven symposia, six industry symposia, more than 320 oral presentations and 170 posters. Spread over two floors and four rooms, the programme offered a diverse and immersive choice to the delegates, providing great depth to topics of past, current and future interest. My personal commitments at the meeting included as one of the 170 posters chosen for presentation, and a podium presentation in the awards session for work performed at Addenbrookes Hospital, Cambridge UK, on registry data. Highlights for me included the symposia and cross-fire sessions held in the main hall, with some of the world’s biggest names in orthopaedics sharing their experiences and debating hot topics, particularly the work presented on registries and paediatric hip pathology. Registries formed the back bone of several presentations, with a keynote lecture from Professor Henrik Malchau from Harvard Medical School on the influence registries will have on clinical practice over the next decade, followed by a registry-specific symposia chaired by Professor Ashley Blom and Emilio Romanini. This included a fascinating lecture from Martyn Porter, Medical Director of the National Joint Registry, UK, on data validity and the consequences of making data public. A hot topic in the UK with the increasing public and government demand for transparency in healthcare. It also provided insight into the setup and management of registries in different organisational cultures, and the different issues and parallels the two societies have had, and still face. Delegate sessions also touched on registries with an engaging presentation during the ‘infection’ session from Mr Keith Tucker. His presentation on the potential role of registries in the monitoring of infections in joint replacements, with interesting foresight in to the future development of registries, database cross-referencing and data analysis, was delivered to a packed room. As with the rest of the meeting, the paediatric symposium had no shortage of world-leading surgeons sharing their views and experience, with Professor Richard Field presenting a summary on hip arthroscopy, and his views on its current and future role in paediatric hip pathology. This was followed by a keynote lecture from Professor Reinhold Ganz

Fig. 1. The Duomo. (who needed no introduction) on the ‘grey’ areas of periacetabular osteotomy. The cross-fire sessions, as expected, provided interesting topics for debate, from the continued role of resurfacing to discussion of the use of cemented or cementless arthroplasty, and on the second day a cross-fire regarding single- or two-stage revision surgery in the presence of infection, hotly debated by Fares Haddad and Rodolfo Capanna with passionate audience participation. In the award session chaired by Congress Chairs Professor Fares Haddad and Presidente Luigi Zagra, we were delighted to be selected for the Best Paper award by The Bone & Joint Journal, for work validating data in the National Hip Fracture Database. This was presented by the conference chairs and Mr John Nolan, President of the British Hip Society, after their welcome speeches. These were just a few of the highlights for me from a very engaging conference. Speakers from around the globe, and in particular those speaking on behalf of the Societa Italiana Dell’Anca, delivered exemplary presentations, especially considering that many were not presenting in

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Fig. 2. Saint Bartholomew flayed.

Fig. 3. Receiving The Bone & Joint Journal award.

their first languages, earning the respect and envy of their linguisticallychallenged colleagues from the UK. Milan is a beautiful city to get lost in, and is one I would return to without hesitation. I would recommend it to all. At its centre is the Duomo, a breath-taking building that has taken more than six centuries to build and sits as one of the largest churches in the world attracting eight million visitors a year. In its transept stands a statue of the patron of my medical school, Saint Bartholomew Flayed, with his skin draped over his shoulder (1562). A haunting statue with an incredible demonstration of surface anatomy and sculpting mastery by Marco d'Agrate; worth a trip in itself. My thanks to Fares Haddad and Luigi Zagra for organising an exceptional meeting, and awarding us with the Prize for Best Paper. I will certainly be looking for more collaborative meetings in the future.

Editor’s note The inscription “NON ME PRAXITELES SED MARCO FINXIT AGRAT” (“I was not sculpted by Praxiteles, but by Marco d’Agrate”) marks d’Agrate out as having the same level of modesty as the average orthopaedic surgeon. Praxiteles was probably the greatest sculptor of the Attic period (4th century BC) and thought to be the first to sculpt a life-size female nude.

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Duncan Cundall-Curry, Trauma & Orthopaedics Specialist Registrar, Addenbrookes Hospital, Cambridge, UK cundall-curry@doctors.org.uk

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S. Putnis

FELLOWSHIPS

The trauma learning curve: in search of a recognised intercalated trauma fellowship to complement UK training

uring the six years of specialist training that it takes to become a consultant, an important set of skills needs to be acquired. The only way to learn these is by seeing patients, communicating with them, and examining, treating and operating on as many different pathological processes and types of injury as possible. The understanding of a condition or fracture will never be as complete through reading alone: there is a learning curve with every surgical procedure.1

Whether the changes in our training over the last ten years now provide us with sufficient opportunities to gain exposure and treat a sufficient volume of injured patients can be debated,2,3 but perhaps it is not just the restrictions and structure of the training itself but the opportunities that a Western society like the UK gives to trainees. The availability of immediate healthcare means that pathology is identified earlier and has less time to progress: the vast improvement in road traffic and industrial safety means we see increasingly fewer trauma cases. Every opportunity to be trained needs to be grasped. Despite this, we may have reached a point where we simply do not get enough exposure to prepare ourselves adequately for the responsibilities of a newly appointed consultant surgeon. After completion of training it is becoming increasingly popular to undertake fellowships which develop the specialist skills and interests needed for the surgeon’s chosen subspecialty. Trauma fellowships are available, as with all the other subspecialties, but are only undertaken if the candidate has a specialist interest in this area. It is standard practice, however, for all new trauma and orthopaedic consultants to be responsible for trauma lists as well as elective procedures in their chosen subspecialty. It is therefore vital that the six years of registrar training comprehensively cover all areas of trauma and in sufficient volume. It has been decided that the training programme should focus on trauma surgery in the earlier years to ensure that sufficient skills are acquired: this early experience should then enable more senior registrars to take on increasingly complex trauma cases. It follows that exposure to trauma should not, therefore,

Image 1. Sunrise at Ngwelezane Hospital, Empangeni, KwaZulu-Natal, South Africa.

Image 2. A typical trauma list board with three theatres running. be at the end of a training programme, but during it. Another way of improving trauma exposure could be to look further afield. At present it is possible to apply for a period of time ‘out-of-programme’. This can be either a ‘training opportunity’ or a ‘learning experience’, depending on how your application is viewed by the Specialist Advisory Committee (SAC). The process can be difficult and is not currently or uniformly available to all trainees in the UK. There is no assistance in finding these placements and no way of establishing exactly how valuable they would be to a trainee; how well-equipped, supervised, mentored or even safe. These are to be found out by the applicant and therefore, understandably, the SAC and training rotations are cautious to allow certification of their potential merits.

A vast amount can be seen and learnt during a six-month attachment to a busy trauma and orthopaedic unit in a developing country. The variety of disease and the frequency of trauma is an eyeopener. If these ‘learning opportunities’ are deemed to be in the right environment for training, then surely this is an opportunity that should be available to all trainees and one that is properly assessed and regulated by the SAC or deanery. For a foreign work attachment to function as a ‘training opportunity’ there needs to be a high standard of care with access to a fully-equipped theatre using modern techniques in fracture management, with adequate teaching and consultant supervision. Essentially, it needs to mimic a training job in the UK as far as possible. As an example of the type of facility that can be visited, I will describe my recent six-month trauma

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Image 3. A photo interruption to the morning trauma meeting. other epidemic”.5 As a result, like many similar tertiary district hospitals, Ngwelezane is extremely busy. For example, last year there were 240 long bone fractures which needed intramedullary fixation and 180 open ankle fractures. Six-month logbook data from UK trainees who have visited Ngwelezane over the last five years has shown first surgeon figures of between 30 and 40 intramedullary nails, 20 to 30 ankle fixations, 20 to 30 hip fracture Image 4. Emergency vehicles gather outside fixations, and 15 to 20 supracondylar Accident & Emergency. fractures, a level of exposure which fellowship at Ngwelezane Hospital, a tertiary refer- would be difficult to achieve in the UK.6 ral government hospital with a catchment of over Hospitals such as Ngwelezane are constantly three million people, situated approximately 150 stretched: many patients may wait for a number km north of Durban in KwaZulu-Natal, South of weeks before being admitted from the priAfrica. I knew that this hospital would fulfil my mary, more rural, hospitals. It would not be needs, having spoken to previous UK trainees who uncommon for a patient to wait between two had spent time there, though without accredita- and three weeks with a closed fracture needing tion this was purely anecdotal. My main apprea femoral or tibial nail, and occasionally longer hension was that the hospital facilities, equipment than a few days with an open fracture. Elective and senior availability would not be comparable theatre time can be extremely scarce, and the with the UK. With frequent media articles on some wards heavily overfilled. These conditions often of the dangers of hijack and robbery in South added invaluable extra challenges to the manAfrica, I also had some concerns regarding how I agement of these patients. Patients with multiwould travel and live while I was there. ple injuries from minibus taxi accidents were a Thankfully the setup at Ngwelezane Hospital weekly occurrence. In one particular case, all was excellent. The department is fully consultant- 12 passengers presented with bilateral lower led with a broad range of international experience limb dislocations or fractures, the level of injury and a clear emphasis on teaching and training. The moving progressively distal in relation to their theatre set-up and access to modern osteosyntheseating position in the vehicle. Compared to sis implants were no different to those in a Western some of the accident victims seen during the hospital. It was also abundantly clear that the rate busy on-call shifts, however, you could describe of trauma was extremely high. In South Africa, these victims as lucky. During one weekend injury-related mortality rates are six times the a total of 141 people died in 110 accidents global rate, and road traffic rates double; a heavy across South Africa, 17 of which were within the burden identified by the World Health Organisa- catchment area of Ngwelezane Hospital.7 tion4 and, more recently, described in the South It is not only the experience with acute trauma African Medical Journal as “South Africa’s that one gains from a fellowship such as this. There

were frequent cases of septic arthritis and osteomyelitis in children, and interesting cases of limb deformity from bone dysplasias and metabolic disease. Blount’s disease is seen regularly due to its increased frequently amongst the Zulu population. Clinics fill early with patients who may have travelled for a number of days, often using overnight government patient transport buses. Access to healthcare can be difficult: many will seek the advice and treatments offered by an Isangoma who practices traditional Zulu medicine. These delays can lead to startling disease progression and push the boundaries of the human body to cope with neglected fractures, chronic infections and tumours. With the broad range of trauma and orthopaedic pathology that one will see on a fellowship such as at Ngwelezane Hospital, it would seem logical that these opportunities are made available, investigated, promoted, encouraged, and subsequently accredited as part of a wellbalanced training programme. References 1. Bjorgul

Novicoff

WM,

Saleh

KJ.

Learning curves in hip fracture surgery. Int Orthop 2011;35:113-9. 2. Eardley W, Parker P, Taylor M. Exposure and experience: a survey of complex trauma caseload and orthopaedic training in the United Kingdom. J Bone Joint Surg [Br] 2010;92-B (Supp IV):546. 3. Eardley W, Taylor D, Parker P. Exposure and experience in trauma surgery – perceptions of United Kingdom orthopaedic trainees. J Bone Joint Surg [Br] 2011;93-B (Supp I):53. 4. Norman R, Matzopoulos R, Groenewald P, Bradshaw D. The high burden of injuries in South Africa. Bull World Health Organ 2007;85:695-702. 5. Saggie J. Trauma: South Africa’s other epidemic. SAMJ 2013;103:589-90. 6. Jameson S, Lamb A, Wallace A, Sher L, Marx C, Reed M. Trauma experience in the UK and Ireland: analysis of orthopaedic training using the elogbook. Surgeon 2011;93-B (Supp I): 26. 7. No authors cited. More that 140 killed on SA roads this weekend – RTMC. http://www.news24. com/SouthAfrica/News/More-than-140-killed-onSA-roads-this-weekend-RTMC-20150831 (date last accessed 18 May 2016).

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Sven Putnis, Specialist Registrar, Royal National Orthopaedic Hospital NHS Trust, UK svenputnis@doctors.org.uk

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J. Tomlinson

Letters

A response to ‘Core surgical trainees: a tribe once ‘lost’ and now ‘forgotten’’ Sir, I read with interest the article ‘Core surgical trainees: a tribe once ‘lost’ and now ‘forgotten’’. It is important as a profession we acknowledge the decline in popularity of our specialty and seek to address it. It is important though that we concentrate on what we can change, and move forwards not back. Although the losses of the firm structure and changes to working patterns have changed team dynamics, we can and must still find ways to meet with junior trainees and engage with them at an early stage. It has been reported that the quality, not quantity of time in theatre impacts on career choice1 - and this can be easily influenced. Lack of prioritisation of education has also been shown to play a role in those leaving surgical training.2 EWTD and shift working has impacted this but it is still possible to create opportunities with lateral

thinking and team working, allowing both time in theatre and exposure to positive role models. Many of us were inspired by our seniors and we need to show more positivity towards our chosen career and inspire the next generation - the role of positive role models in career choice is well-recognised.3 A career in surgery will always require some compromises, and the evidence suggests today’s trainees value work-life balance highly.4 It is important then that we shout from the rooftops about the rewards of a career in orthopaedics - the future workforce is ours to inspire. Yours faithfully, J. Tomlinson References 1. Hagopian TM, Vitiello GA, Hart AM, et al. Does the amount of time medical students spend in the operating room during the general surgery

core clerkship affect their career decision? Am J Surg 2015;210:167-72. 2. Bongiovanni T, Yeo H, Sosa JA, et al. Attrition from surgical residency training: perspectives from those who left. Am J Surg 2015;210:648-54. 3. Healy NA, Cantillon P, Malone C, Kerin MJ. Role models and mentors in surgery. Am J Surg 2012;204:256-61. 4. Smith F, Lambert TW, Goldacre MJ. Factors influencing junior doctors’ choices of future specialty: trends over time and demographics based on results from UK national surveys. J R Soc Med 2015;108:396-405. A uthor

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James Tomlinson, Advanced Spine Fellow, Leeds Teaching Hospitals, UK jet@doctors.org.uk

R. Checketts

Reflections on ‘Current concepts I don’t believe in’ Sometimes the tests were undoubtedly positive,

I am disappointed that the training we were given

but sometimes more subtly positive. This is why the

by our experienced teachers, and the systems that

I read the article on ‘Current concepts I don’t believe

examiners need training and experience. If the hip was

were set up to diagnose and treat these conditions,

in’ by David Jones in the latest edition of BJJ News with

found to be dislocated or dislocatable, the hips were

have apparently fallen into disuse. It’s not rocket sci-

great interest, and some disappointment.

held in abduction in the reduced position whilst an

ence, but it is important that the protocol is followed.

I agree with almost all of the points made by David

experienced nurse applied a Dennis Browne hip

Examination of the newborn hip is not something that

Jones. His paediatric practice was almost identical to

splint. Pavlik harnesses were never used. The mothers

can be delegated to inexperienced juniors.

my own. I was trained in Sheffield by Sir Frank Holds-

were invariably distraught and needed a lot of reassur-

At the risk of being thought of as a dinosaur, I am

worth, WJW Sharrard and David Evans, who were all

ance, particularly from the nurse. The parents were

also very disappointed by the loss of the ‘firm’ system

presidents of the BOA, and in Glasgow at the Hospital

instructed not to remove the splint for any reason. The

of training. As well as being taught surgical technique

for Sick Children by Noel Blockey.

nurses taught them how to care for their babies in the

by an experienced consultant, the trainees were able

Noel Blockey had a precise approach to CDH and

splints. After application of the splint, they were ini-

to imbibe the orthopaedic philosophy of their various

wrote authoritatively on its management and treat-

tially followed up weekly by the nurses to ensure that

consultants. Loss of this apprenticeship system, I have

ment, particularly in late recognised cases.

they were coping, and then later, every two or three

no doubt, has been a very retrograde development in

weeks.

orthopaedic training.

Sir,

At Sunderland Royal Hospital there was a large busy maternity hospital on site. Together with the pae-

The splints were removed at eight weeks. After-

Incidentally, regarding the modern term DDH, the

diatricians I was able to set up a CDH service. All new-

wards the babies were seen at nine or ten months,

dictionary definition of congenital is “any nonheredi-

borns were examined by a paediatric consultant or a

and a radiograph taken. If the X-rays showed the hips

tary condition existing at birth”, hence CDH. Do dislo-

senior paediatric registrar. All those where there was a

were in joint, which was invariably the case, they

cations occur de novo later than the neonatal period, or

suspicion of hip instability were referred to me, and

were discharged. I cannot recall that any needed later

could these be ones that have been missed at the neo-

were seen by me with a senor trainee. The trainee was

surgery.

natal examination?

given the opportunity of examining the baby first, and

Radiographs at an earlier stage are not helpful and

Yours faithfully,

then their findings were confirmed by me using the

not recommended, as the femoral heads and the proxi-

R. Checketts

Barlow and Ortolani tests. It is essential thatthe exami-

mal femurs are unossified. As the diagnosis of a dislo-

nation is carried out in a quiet warm room: the examin-

cated or dislocatable hip is clinical, and in experienced

ers hands must also be warm. The baby should have

hands reliable, ultrasound was not used.

been fed just beforehand. It is not possible to examine properly a crying distressed baby.

All our late diagnosed cases came from outwith the catchment area of the maternity hospital.

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Roger Checketts rogerthebone@yahoo.co.uk

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G. Walker

The early days of the Orthopaedic Training Project, Addis Ababa Sir, In his excellent article ‘A ‘faranji’ in Addis’, published in BJJ News (September 2015), David Jones makes brief mention of how World Orthopaedic Concern (WOC) became involved in the creation of the Orthopaedic Training Project at the Black Lion Hospital, and is happy that I am now expanding on what he described. I think it was in 1985 that as Secretary of the slowly developing UK region of WOC, I received a request for help with the establishment of a separate orthopaedic department and training scheme in Addis Ababa. This request for assistance originated from the then current Head of the Surgical Department at the Black Lion Hospital (BLH) in Addis, and had been forwarded to me either by the British Council or the UK government, as I was then helping the late J.N. ‘Ginger’ Wilson with the creation of WOC UK. I passed this letter to Ginger who undertook appropriate mildly complex negotiations with the UK government. These involved discussing accommodation, salary and the length of possible support. At first the UK government suggested that help for six months would be adequate to train the first group of Ethiopian orthopaedic surgeons. This was obviously quite ridiculous, so with the help of appropriate friends in high places, it was agreed that a new orthopaedic training project in Addis would receive UK financial help for four years, and that all the necessary administration would be managed by the British Council. As a result, Ginger Wilson persuaded the late Reginald ‘Reggie’ Merryweather to go to Addis; he arrived there during January 1987 and stayed

until May 1989. During this period he was greatly helped with the establishment of the Orthopaedic Training Project by the late Dr Ron Garst, a remarkable American missionary orthopaedic surgeon who had already established an orthopaedic training scheme in Ludhiana, India. Ron Garst was a most remarkable man whom I grew to know well during my early visits in the 1970s to the training scheme he was setting up in Dhaka, Bangladesh very soon after their separation from West Pakistan in 1972. Ron was an expert in persuading relevant government and other officials to accept his suggestions, and when I arrived in Dacca five months after the war, Ron already had 150 orthopaedic beds supported by four functioning orthopaedic theatres. Ron was thus the ideal person to spend time with Reggie in Addis, and together they established a four-year training scheme which also included working in general surgery, anaesthesia and radiology. I had agreed to follow Reggie, but as I was then moving house, Ginger Wilson and Brian Madden each spent a few months in the new orthopaedic department at the BLH until I was able to arrive in Addis early in 1990. At that time there were already two other senior doctors in the Department. Dr D.N.Singh, an Indian orthopaedic surgeon, and Dr Tesfaye Gebreyes an Ethiopian general surgeon who had spent some time studying orthopaedics in Edinburgh. The orthopaedic training scheme had already started with a total of 13 trainees. Four in the final of four years, five in the third year, and two in each of the second and first year. The senior year included one from the Yemen, who returned home after passing his final examination.

Unfortunately during the early years of our training scheme, the popularity among Ethiopians for becoming an orthopaedic surgeon was not as great as training as a general surgeon, but this situation has steadily improved and now there will soon be 77 orthopaedic trainees. However as there are insufficient facilities at the BLH (only 60 orthopaedic beds) for this steadily increasing number, our trainees now spend part of their four year training in four other hospitals which have active orthopaedic departments. It is pleasing that both our trainees and trainers all appreciate these additional training opportunities. It is only fair to mention that colleagues from the USA had been visiting and teaching orthopaedics at the BLH for quite a while before the official training scheme was born. A Dr Anderson was very active in this respect, and I think that he may have been born in Ethiopia. I was able to welcome several US teachers during my time as Professor, and some of these made repeated and very helpful visits. Although now 88 years of age, I maintain my interest in this training scheme and hope that other elderly colleagues who can remember how to use plaster and traction will continue to help to train our keen young colleagues in Ethiopia. Anyone interested should contact WOC UK – or even me. Yours faithfully, G. Walker A uthor

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Geoffrey Walker, Retired Orthopaedic Surgeon, UK Geoffreyf2.Walker@gmail.com

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APPRECIATION

Frank Horan rancis Thomas (Frank) Horan, who died suddenly on 10 November 2015 following major surgery, was one of St. Mary’s Hospital Medical School’s more colourful characters. He was of that generation (born 1933) which was yet to acknowledge ‘Imperial’ College. His story, depicting a climb to honour, was unusual and irregular, but unlike a rollercoaster, the general slope was upward, with the highest points last. He was the only son of a large Mancunian family, which migrated to Devon at the time of the great Recession. Even from that very early age, he had been indelibly imprinted with the red shirt of ‘United’. There followed several abrupt and seminal changes in his circumstances, but none supplanted the Old Trafford genes. His early schooling was at the Torquay Grammar School, where he achieved sufficient grades for acceptance at the Medical School of St Mary’s Hospital, Paddington. Medicine had not been his childish ambition, but his mother’s strength of character made the decision. His initial year at SMH was disturbed in many ways, not least by the requirement he felt to speak differently and to play football with an oblong shaped ball! Little is recorded of this tumultuous year but suffice to say that at the end of it, he failed the examination and was unceremoniously sacked. In 1951 he was obliged to perform his National Service, which he did in the Royal Air Force as a radar operator for Fighter Command. During that time, he spent long hours preparing himself academically. Clearly the sting of his earlier failure was a driving force; he achieved his goal in Dublin and immediately appealed for re-instatement at St Mary’s. Against the current trend, he was successful. The years at medical school were coloured by lasting friendships with (inter alia) Peter Beighton, a fellow Lancastrian, both scholarly and amusing, who later became a Professor of Genetics. Later they were to write articles on dysplasia and deformity, traveling about the Western Cape discovering new inherited diseases. Frank was what one used to call ‘clubable’ - a natural joiner of Societies and a participator in team sports. At rugby, as a forward in the St Mary’s B XV, he developed a style of play which might best be called “combative”. - his son Tom’s word. Proceedings in the secrecy of the set scrum are best kept sacrosanct. He played many sports to a medium proficiency; none brilliantly, but all suggestive of a better standard in the past. Most important of these was cricket where his ‘military medium pace’ trundles were treated with respect. When the writer of this essay dropped a catch off his bowling, he was never forgiven (even though the ball was a rank long-hop!) Frank was not naturally academic and had some difficulty along the way, but he qualified eventually through the Conjoint exam, and then proceeded through the various stages of surgical training. Frank was the most loyal trainee, choosing his role models with instinct and skill. Each one left a mark on Frank’s character; he was like a chameleon, absorbing colour and characteristics, and tending to act and speak like each of them in turn. They included Pete Beighton, Pat Chesterman, Lester Lowe, John

M. Laurence

1933 – 2015

Crawford Adams and of course George Bonney. He even picked up slang expressions and accents – even the affected stutter of George Bonney, but he never quite acquired the Etonian brogue. He spent a year (1974) in Montreal returning with the degree of MSc and was appointed as consultant to the prestigious county town of Cuckfield, Sussex, in 1975. He devoted his energy and firm leadership as Medical Director (from 1991) to the hospital’s staff and its reputation, seeing through its transition into the Princess Royal Hospital at Hayward’s Heath. Frank was always a forceful and extremely effective speaker, both in private and public. He took few pains specifically to please people and in fact did make some enemies, but at the same time he gave and attracted profound loyalty. He kept his friends and was always seen at Hospital Cup matches and frequently at Internationals. He was a vigorous supporter of the St Mary’s Orthopaedic Postgraduate club, and anything strictly ‘Mary’s’. To some he seemed to delight in confrontation, with powerful biases, commonly derived from those he admired most, and when he quoted them, he assumed their mode of speech. As a verbal fighter he developed a conspicuous medico-legal practice with a reputation for clear enunciation of points of law in Court.

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Close friendship with colleague Tony Hall lead to a collaboration in the high offices of the worldwide Orthopaedic Society, SICOT. Both were appointed honorary life members of the Society with significant influence on the SICOT Diploma examination and their journal, International Orthopaedics. Frank chose his extramural activities in accordance with his personal passions. He did some private practice and attended the well-known Sports Injury Clinic which Bill Tucker ran in Park Street, integrating with Bill’s somewhat idiosyncratic nature. He was a founder member of the British Association of Sports Trauma, and looked after Olympic teams on whose medical advisory boards he sat. He associated himself with Sussex County Cricket Club and the MCC. The regularity of his attendances at Lord’s and his robust, unaffected approach to injured players, endeared him to the physiotherapy staff at Lord’s, and then to every player (from every country) at the ground. His solid reliability made him the cricketers’ adviser, be they test match or club standard. In 2006 he was made a Life Member of the MCC. His devotion to the game took on an intensity verging on the religious, and his political allegiances also tended toward extremism. But by far the pinnacle of his career began with his invitation to join the Editorial Board of The Journal of Bone & Joint Surgery [Br] in the 1990s, with the warm encouragement of John Crawford Adams. Quickly he became the ’Orthopod on the Clapham Omnibus’, the man whose feet were secured to the orthopaedic ground, whose mature judgement related to general orthopaedics, whereas everyone else was breaking the bounds of medical rarity, to the point of obscurity. In this way he was a powerful influence in the maintenance of the journal as ‘general’, against the trend towards specialties. He was appointed Editor in 1997, in succession to Philip Fulford; both had maintained the principal dedication, laid down by Christopher Catterall, that the Journal was not for the specialist alone, but must address the needs of the distant, lonely, orthopaedic surgeon working at the northern end of the railway line in Mandalay! It was Frank who gave constant reminders of the needs of remote and under-resourced places. There were (intentional) clashes at the editorial board meetings, but it was the force of Frank’s opinion (not always expressed) which made him

indispensable. Disagreements occurred with the subspecialists, with such established experts as John Fixsen and Leslie Klenerman, but Frank never lost an argument; it just happened that in the course of debate, their opinion emerged as his. This was the essence of the great Chairman and made him the perfect Editor of the Journal. The board meetings had an excited tension shared by all present. None was ever excluded from the final opinion regarding acceptance or rejection for publication; and always there was an atmosphere of great wit, wisdom and jollity. He elected to step down from the chair in 2003, though not from the work. Between 2003 and 2011, he was given the title of Editor Emeritus – not an honorary appointment, but one enabling him to continue to provide his input in subediting and informal guidance. Very few of the publications in the Journal between 1995 and 2011, did not bear marks of Frank’s ‘clarifications’, although few authors ever realised that fact. This lead to fruitful collaboration with James Scott, his successor in the editor’s chair. In his negotiations through rough waters, Frank had to cope with personal catastrophes. His son John, a most gifted barrister, was struck down with a cerebral haemorrhage and now has hemiplegia, and the illness of his beloved wife, Cynthia. His was a life peppered with disappointment and difficulties which proved to be the inspiration for dedicated work which brought great success. Right to the end, Frank maintained his quick wit, his rapid analysis of a problem and firm capacity for decision. This life was a triumph of argument and reasoned discord, providing not so much a breath of fresh air, as a gale through committee debate. He is survived by a lively family (Cynthia, John, Tom and Julia), whose cohesion owes everything to his spirit for survival over adversity, without the impression of having triumphed.

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Michael Laurence, Retired Consultant Orthopaedic Surgeon, UK mikelaurence81@gmail.com

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30th Edinburgh International Trauma Symposium and Trauma Instructional Course Edinburgh International Trauma Symposium 17th – 19th August 2016 The Symposium is aimed at established orthopaedic surgeons with a trauma practice. A faculty of international and national experts will cover advances and controversies in the management of regional orthopaedic injuries, as well as the diverse challenges presented by multiple trauma, mass casualties and fragility fractures. Fee £750 (three days)

Edinburgh Instructional Trauma Course 15th -19th August 2016 This popular course provides a complete overview of orthopaedic trauma from head to foot, encompassing paediatric and adult injuries, fragility fractures in the elderly, spinal injuries, and the complications of trauma. The level of the course is aimed at the orthopaedic Fellowship examination and is also suitable for established surgeons wishing for a general update, new trainees requiring an overview of the subject, and senior nurses and physiotherapists. Fees £800 (five days)

INVITED INTERNATIONAL FACULTY INCLUDE

Professor Heather Vallier (Cleveland, Ohio), Professor Mike McKee (Tornto) and Professor David Ring (Boston). Venue: Sheraton Hotel, Edinburgh, Scotland. About Edinburgh: Edinburgh is Scotland’s capital city, a World Heritage Site and has a proud history of medical education and research. It is a vibrant city famous for its hospitals, International Festival and Fringe Festival.

Format AT THE EDINBURGH SHERATON HOTEL: • Short, focused lectures • Debates • Ample time for case-based discussion • Break-out sessions for more in-depth expert analysis • Dry-bone skills labs

AT THE UNIVERSITY OF EDINBURGH MEDICAL SCHOOL ANATOMY DEPARTMENT: • Cadaveric sessions focusing on surgical approaches and fracture fixation. Further information and a detailed programme are available on our website: www.trauma.co.uk or by email: symposium@trauma.co.uk.

SPONSORED BY The Orthopaedic Trauma Society