BJJ News Issue 12

BJJ News | I ssue 9 | D ecember 2015

BJJ News from The Bone & Joint Journal

Formerly known as JBJS (Br)

BJJ News | I ssue 12 | D ecember 2017

Issue 12

Current Concepts

Current opinion in conservative hip surgery Orthopod’s view

Medical writing is becoming more difficult to read: official A. Ross p16

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J. Witt p7

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CELE JJ BRA 70 YE TING ARS

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BJJ News

Issue 12

from The Bone & Joint Journal

December 2017

Editorial Editorial

A. Ross

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What I wish I had known when I started in orthopaedics

M. Laurence

2

Subspecialisation

C. Faux

3

J. du Toit

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J. Witt

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Orthopod’s view

Notes from the road Orthopaedics in South Africa

Current concepts Current opinion in conservative hip surgery

Medico-legal When the tail wags the dog in medicolegal practice

M. A. Foy

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J. Kirkup

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J. Scott

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A. Ross

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N. Gittoes

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History One Hundred Years of Surgery Using Stainless Steel

Art Kenneth Armitage and the Arts Project at the Chelsea and Westminster Hospital

Orthopod’s View Journal Office: 22 Buckingham Street, London WC2N 6ET, UK bjjnews@boneandjoint.org.uk

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

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A Bone & Joint Publicat ion THE BRITISH EDITORIAL SOCIET Y OF BONE AND JOINT SURGERY. Registered charit y no: 209299.

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Medical writing is becoming more difficult to read: official

Letter National Osteoporosis Society Clinical & Scientific Committee Response to Today programme, BBC Health Website and Inside Health coverage of bisphosphonates and osteoporosis

www.wcb2018.com wcb2018 In conjunction with

Call for Abstracts Now Open

Registration Now Open

Submission Deadline 19th December 2017

Plenary Speakers Prof Elazer Edelman Harvard-MIT, USA

Prof David Elad

Tel Aviv University, Israel

Prof Jay Humphrey Yale University, USA

Prof Takuji Ishikawa Tohoku University, Japan

Prof Chwee Teck Lim

Prof Merryn Tawhai

Prof Lori Setton

Prof Xavier Trepat

Prof Julie Steele

Prof Clemens van Blitterswijk

National University of Singapore, Singapore

Washington University in St Louis, USA

University of Wollongong, Australia

University of Auckland, New Zealand

IBEC Barcelona, Spain

Maastricht University, The Netherlands

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BJJ News | I ssue 12 | D ecember 2017

A. Ross

Editorial

ast year I finished ten years as an examiner for the final FRCS (Tr&Orth) exam. It is a remarkable experience that I would thoroughly recommend to those who are so inclined. As a distinguished ex-chairman of ours used to say, it is one of the best possible orthopaedic educational experiences – and by that he meant for the examiners. It is a salutary reminder as to how much one forgets over the years, and one also gets to meet many of the future stars of orthopaedic surgery. While lecturing in London recently, I barely managed to escape with my life having discovered that I had examined three of the four senior staff on the unit (they all passed!).

With these thoughts in mind, I have been pondering the future of the exam. Let me say at the outset that I think it is one of the fairest and best-organised methods of assessing our future orthopaedic consultants. From standard-setting to the prompt delivery of results, it runs like a well-oiled machine. For those who have failed to reach its rigorous standards, I would simply reiterate the time-honoured maxim that examiners genuinely try to pass candidates. It is the candidates themselves who, on occasion, dig themselves into a hole from which it proves impossible to escape.

It is not the exam itself that concerns me; it is how it hopes to maintain its current approach in a world where surgeons are becoming increasingly subspecialised. Candidates are expected to have the knowledge of a first-day consultant in a district general hospital but without a specialist interest. However, given that the younger consultant examiners have to be of at least five years’ standing and have all, by this stage, been specialising for the same period of time (and the older ones a good deal longer), do they really retain all the contemporary knowledge needed by the firstday consultant for that length of time? We have all learnt topics for exams that have promptly evaporated after their successful completion. One tends only to retain the highlevel information needed to practise on a day-to-day basis.

Unfortunately, the musculoskeletal system doesn’t understand this and has the unfortunate habit of referring pain.

Consequently, the patient who presents the knee surgeon with pain radiating from the back or hip, or the patient who presents the hand surgeon with pain radiating from the neck, may be at a relative disadvantage. Those of us who have been in practice for 30 years or more see problems associated with this on a regular basis. In this issue, Chris Faux describes, in his characteristically direct manner, several examples of this. I could add at least a dozen more

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and so could my colleagues. Where, then, are we to find the examiners of the future with the appropriate range of general orthopaedic experience who are capable of examining the ‘adult and pathology’ section of the oral examination?

Will it have to be split into examination by region, with shoulder, elbow, spine, hip, knee, and ankle and foot sections? I do hope not. We already have specialist examiners for hands, children and trauma. Better to ensure that candidates and examiners remain broadly versed in general orthopaedics.

There is an alternative, however. In my professional lifetime, I have watched the general FRCS examination divided into, I believe, ten different subspecialties. Is this the future for the FRCS (Tr&Orth) exam? Currently, albeit with some exceptions, patients with all but the simplest fractures tend to have to wait for treatment until a surgeon with an interest in that particular joint is on call. So the shoulder surgeon deals with shoulder fractures, the knee surgeon with knee fractures, and so on. Might this lead to subspecialist FRCS examinations for each of the joints that encompass both elective and trauma surgery, such as the FRCS (hip surgery)? Were this to be the case, then why train to operate on any other joint? A basic undergraduate training in medicine, followed by a couple of foundation years then straight into hip surgery, or knee surgery, or foot and ankle surgery.

It seems to be the way things are going. It is usually possible to identify the preferred speciality of an individual candidate, and one knows of trainees who spend as much time as possible working for surgeons in their preferred specialty who nevertheless manage to pass the FRCS exam by ‘mugging up’ the other areas.

There is, however, one major drawback to this approach.

If a surgeon is going to spend 30 years operating on the same joint to the exclusion of all others, is ‘orthopaedics’ going to continue to attract the brightest and best? For one who has derived much pleasure and intellectual stimulation over the last 35 years by maintaining a broad interest, I do feel that concentrating on one joint, rather than considering the whole patient, might, with the passage of time, prove to be a little dull.

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

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BJJ News | I ssue 12 | D ecember 2017

Orthopod’s view

M. Laurence

What I wish I had known when I started in orthopaedics

hen I started in orthopaedics, things were very different indeed.

(Why I started is an easier question to answer, but less interesting). I recall a wise old ‘uncle’, who in his turn was told by his father, “Doesn’t matter much what you choose to do in life, son. I give you one piece of advice – pick a bad trade.”

I make no further comment on that, but to say that our generation has been blessed to take part in extraordinary development and discovery. We had the unique opportunity, not only of witnessing it, but of taking a leading part in it.

We were learning as fast as were our teachers, who were unlike those of Arbuthnot Lane, who was hounded from the profession by his peers for daring to operate on fractures, or the Barber Surgeons of half a millennium ago, who ­disdained the title ‘Doctor’ for a similar reason.

Swept along by this golden opportunity, we were on the crest of a tidal wave, and could not have been happier. I loved every minute and could not understand the rumblings of discontent within the profession, which have developed so inexorably over the recent years.

I look back with some regret that we were so excited by the brilliance of the inventions since the middle of the last century, as to indulge that passion and neglect our debt. We allowed the influence of modern surgery (in our case orthopaedics) to pass into the hands of accountancybound politicians.

Not for a moment do I think that I, personally, could have made any significant difference, but our whole generation were passively guilty of scorning the administrators; we took little or no part in decision-making. Ours was the only opinion that would have been based on experienced practice. So we allowed monetary considerations (= threadneedlespeak) to dominate the world’s care of unfortunate victims of the accidents of inheritance, disease and trauma.

My feelings are not political, but pragmatic and social. I feel little antagonism towards Premiership footballers, nor to entrepreneurs nor inventors. But society has a duty of care towards all its citizens. We should remember the legal action brought by Professor Rajasekeran (Coimbatore) who took the Indian Government to the

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Supreme Court for its failure of care of its citizens, and won, bringing the Government down.

Perhaps one might blame a lack of collegiality or team spirit, but it is worse than that. To a degree it was selfishness, a failure to realise that each one of us owes a debt of gratitude to the very subject of our speciality and to those who taught us. In hindsight, we feel a sense of failure towards our forebears and successors. We have failed in not setting aside more time to the organisation of the community of orthopaedics, to committees; and it has overwhelmed us.

This is not attributable to disappointment at not having personally sought high office; but, at the grass roots level, orthopaedic surgeons (in particular) have tended to plough a lonely furrow, devoting all their time to their clinical practice.

At the same time, specialism has blinded us to the equally dramatic development in other branches of surgery. The tree of technology has grown so far and wide as to put our erstwhile colleagues on opposite branches of the tree, out of our sight.

When I started in orthopaedics, the administration of the whole hospital was in the generally benign hands of honoured captains of industry together with the 25 consultants of the hospital consultant staff who met regularly. I very rarely attended. When I retired, the consultant committee measured over 300. The consultant dining room had closed, through disuse.

We were divided and ruled by market forces.

The effect was the disruption of the team, and having been dispersed, we lost all influence. Patient care no longer dominated hospital policy. It fell victim to accountancy and politics, into the hands of those with political ambition (who tended to be those of diminished ability).

If we had realised it then, we should have made vigorous efforts to protect the NHS hospital from domination by trivial ailments, private pride and balance sheets. Perhaps the numbers were too great: 25 is a team; 300 is a mob. The need was for concerted, united leadership, which has to be given, not commanded.

The members of a Club meet each other by accident, and incidentally talk with each other,

by which means agreements emerge. Personal interests are replaced by those of the community, wisely organised.

The current ‘Commentary’ from the Royal College of Physicians (of England) contains reports from the hospitals serving the immediate aftermath of the Manchester bombing, the London Bridge knife attack and the Grenfell Tower fire. They depict dedicated automatic teamwork and a sense of achievement in its performance.

Hospitals are by no means the only unit of the NHS. Numerically they serve a minority of the population; their A&E departments need to be strictly protected. We are obliged to double tiers of treatment. Hospitals must no longer be expected to cover General Practice, out of hours.

They manage the highest levels of obscure science, not the fundamental day-to-day maintenance. A nation’s duty is to provide for everyone who is in need; there is no obligation for everyone to have some ‘hospital time’. The loss of General Medicine (and likewise General Surgery) has resulted in some degree of neglect of the ordinary common conditions that need medicine or surgery, but of no complexity. Specialities are essential in the broad scene, but they must grow out of the general, not compete with it. All these matters require medical knowledge and experience, not a knowledge of commerce.

Little of this was foreseen 30 years ago – still less 60 years ago. That was when wisdom was required. In answer to the question, “how might I have decided differently?”: well, perhaps I wouldn’t have done; not in my case. I have conceit enough to believe I did some good.

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Michael Laurence, Consultant Orthopaedic Surgeon mikelaurence81@gmail.com

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BJJ News | I ssue 12 | D ecember 2017

Orthopod’s view

C. Faux

Subspecialisation

hen I was appointed as a consultant in 1977, we were all general and traumatic surgeons, most of whom developed a special interest. Low back pain was about 40% of the work load: my weekly list consisted of two hips, one knee, one back and ten day cases, which included caudal epidurals and facet joint injections. Pain relief clinics as such were rare. New clinics consisted of 25 new and three emergency GP referrals and as many follow-ups as created by throughput.

Several recent cases have come to light that are disturbing.

An eighty-year-old with back, buttock and thigh pain was referred to a spinal surgeon. An MRI showed spinal stenosis: an operation was advised and carried out. The wound eventually dried up and a telephone follow-up at six weeks advised that the thigh pain would settle as it was early days and not to worry. The patient’s toe nails proved difficult to trim and a visit to a local chiropodist provoked the question: “have you had a Doppler?” as the chiropodist was unhappy about the colour and warmth of the patient’s feet. A Doppler showed complete obstruction of the femoral artery at the groin on one side and partial obstruction of the other. A stent and a bypass relieved the residual thigh pain.

A working man aged 63 years fell after a night out, injuring his hip. He attended A & E. Radiographs, reported by a radiographer, showed no fracture. He was told that he had a soft-tissue injury and was allowed home. Ten days later he was still in pain and attended his GP who referred him back to the orthopaedic clinic. No check film was taken and he was referred to a hip specialist who advised an MRI to rule out a labral tear.

Again, no check film was taken at the specialist clinic. On arrival for his MRI scan he was found to have a Garden grade IV fracture of the neck of the femur. Review of the radiographs from A&E showed a Garden grade I fracture. Previously, most medical students and certainly all Casualty Officers were advised to do check films with this history. Apart from the unnecessary expense of a scan, the patient suffered additional pain and developed a displaced fracture with all the attendant consequences.

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A 60-year-old farmer developed night sweats, weight loss and pain in the chest and back, and was referred to the local chest clinic for further investigation. Obvious investigations for TB, brucellosis, etc. were all negative. After three months the penny dropped and he was found to have metallosis from a hip arthroplasty implanted five years earlier. The changes were present on pelvic radiographs but not reviewed for three months!

Another case, and these are all from different areas of the UK, concerns a 67-year-old man who had significant low back, buttock and leg pain for six months and was referred to a spinal clinic where a scan showed spinal stenosis. Surgery was advised but he asked for a further opinion and was sent to a pain clinic and advised to have an epidural and an X-ray of his hip. On admission for the epidural, his wife asked about the result of his X-ray and was told “Oh, we will check now”. The radiograph showed bone-onbone osteoarthritis of the right hip, at which point he underwent an injection into that hip, the epidural was cancelled and he was referred onto a specialist hip surgeon.

A further case: “Dear Doctor, please see this delightful lady with a painful right knee. She has had this for six months and it has not responded to NSAIDs and exercises. An X-ray shows early changes of OA.” The clinic letter replied: “Examination in the clinic showed that the affected limb was short by an inch with a range of hip flexion between 20° and 80° with a painful jog of rotation. X-ray confirmed the clinical diagnosis of advanced OA of the hip and I have sent her on for a THR”!

We have here a catalogue of cases where the simple rules of my generation have not been applied by specialist clinics and a full examination was not carried out.

History and examination are paramount: ­further investigations should only confirm the clinical diagnosis (Lord Cohen of Birkenhead).

Local pain must exclude referred pain from another region. Examination must include “look, feel, move, strain and X-ray”, as described

by Alan Apley. Any joint that is still painful two weeks after a fall should be x-rayed again.

I am very happy to have experts, but we must not forget our basic training and try to get it right first time. One should never forget the description of an expert as “someone who knows more and more about less and less until eventually they know everything about nothing”.

In my present job I have been trying to bring the lack of orthopaedic training to the attention of my employer, the past two presidents of the British Orthopaedic Association and the local deanery. The only response has been from the President of the Royal College of Surgeons, an orthopaedic surgeon, who suggested I contact the local deanery, which I have done.

There is nothing wrong with subspecialisation, but please can we look at the big picture, think outside the box and get back to basic training!

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Chris Faux, Consultant Orthopaedic Surgeon chrisandpattifaux@btinternet.com

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Notes from the road

Orthopaedics in South Africa

he Republic of South Africa, its healthcare services and subsidiaries, including orthopaedics, continue to defy attempts at standard categorisation. One is vividly reminded of the new Audi Q2 ‘#untaggable’ campaign: not quite a SUV or a sedan; maybe a very strange-looking hatchback but definitely a ­‘wannabe’ off-road utility; beautiful to look at but increasingly expensive to purchase and maintain, when one considers the woeful performance of the South African Rand. This vehicle exhibits exceptional characteristics and hints at promise, but (alas) intermittently struggles to achieve its potential when asked to perform a unique task in a specific setting.

The categorisation of countries as belonging to the First, Second or Third World reflects an outdated geopolitical world view that hails from the Cold War era. Somehow, the Oxford Dictionary’s definition of a developing country as “a poor agricultural country that is seeking to become more advanced economically and socially” also lacks conviction when attempting to describe South Africa, its healthcare systems and orthopaedics. Maybe it would be more apt to refer to ourselves as a ‘Developed Developing’ country?

The fact is that health care in South Africa is unique in that the care provided, as well as the population being served, is extremely diverse, ranging from highly developed to extremely underdeveloped. The net effect encompasses a diverse scope of hugely positive, but also very negative, aspects when assessing the status of health care and orthopaedics in South Africa. Bluntly stated, South Africa has relatively poor health outcomes given its level of economic development.1

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Why is this the case?

The burden of disease in sub-Saharan Africa is five times higher than in established market economies.2 In developed countries the disease profile is changing from one of infectious diseases to that of chronic degenerative disease (Double Disease Burden). The Southern African Development Community region, however, is faced with unique additional challenges, the so-called Quadruple Disease Burden:3 1. Poverty-related illnesses: infectious diseases, other communicable diseases, maternal causes, perinatal conditions and nutritional deficiencies.

2. Non-communicable diseases.

3. HIV/AIDS and tuberculosis.

4. Violence and injuries.

All four of these concurrent epidemics have a direct impact on our orthopaedic healthcare burden. Violence and injuries, in particular, are threatening our ability to render appropriate orthopaedic care in all spheres for which we are responsible.

For example, what is the impact of road injuries on orthopaedic health care in South Africa? The total number of orthopaedic injuries as a result of road injuries in South Africa is unfortunately not available. However, let us employ a measure of ‘poetic licence’ and extrapolate from the available data in our quest to gain some perspective. A total of 528 946 people

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died in South Africa (population ~ 53 million) in 2012, of which a jawdropping 9.6% (or 50 778 deaths) was attributed to injuries. Of these 528 946 deaths, 3.3% (or 17 455 people) died as a result of road injuries.1 A number of sources claim that this figure is, in fact, much higher. A global estimation by the World Health Organization concluded that you can expect between 16 and 40 non-fatal injuries for every one person who dies as a result of a road accident. About 50% of these patients will present with a significant orthopaedic-related injury. We can thus expect to treat between 139 640 and 349 100 patients with significant orthopaedic injuries per year due to road traffic accidents alone. When considering that road injuries are not the main culprit when identifying causes of injuries within South Africa, but that non-accidental trauma is the most common, it is glaringly obvious that the effect of injuries on the orthopaedic healthcare system in South Africa has assumed tsunami-like proportions.

These sobering statistics, when combined with the increasing rate of degenerative diseases, orthopaedic manifestations of HIV/AIDS and tuberculosis, and other musculoskeletal infections, place a massive burden on our ability to effectively and timeously manage these patients.

The impact of HIV/AIDS on orthopaedics is difficult to define. With 18.9% of the population between 15 and 49 years being HIV-positive, one would expect a massive rise in infection, nonunions, avascular necrosis of the hip etc, but the reality is that HIV has not significantly changed how we practise the art of orthopaedics. Good-quality longitudinal studies are needed to clearly define the impact of HIV on orthopaedics within South Africa.

The disparity in health expenditure is another area of concern. A perfectly reasonable 8.9% of our Gross Domestic Product (GDP) was

BJJ News | I ssue 12 | D ecember 2017

allocated to healthcare in 2015 but, unfortunately, selective statistics can be very deceiving. Over 80% of the population is totally dependent on the public sector health system, which is largely funded by general tax revenue. However, this sector only accounts for about 40% of total health expenditure. The private sector serves 20% of the population and is funded largely through private medical schemes, but accounts for about 60% of total health care expenditure.4 This obviously leads to huge imbalances in expenditure. The dismal rate of exchange and the fact that we acquire most of our consumables from foreign sources contribute to a pretty empty ‘pot of gold’.

Another problem, which goes hand in hand with the disparity in health expenditure, is the shortage of human resources in the public sector. In 2012, South Africa had only 0.7 physicians and 1.1 nurses per 1000 population,5 which is well below the average when compared with other developing countries. There are an estimated 700 orthopaedic surgeons practising in South Africa. The mean ratio of surgeons to patients in the private sector is 5 per 100 000, which compares reasonably well with developed countries. By contrast, the rate of 0.37 orthopaedic surgeons per 100 000 people in the public sector is a grave cause for concern. This obvious disparity in the utilisation of essential human resources speaks for itself.

Additional factors that contribute to deficiencies in orthopaedic healthcare include the lack of theatre availability, a poor peripheral orthopaedic footprint at primary and secondary levels, the availability of orthopaedic equipment and consumables and the ever-increasing threat of litigation.

Let us place this in perspective. Tygerberg Academic Hospital, a tertiary institution in the Western Cape affiliated to the University of Stellenbosch, renders tertiary care to approximately 3.1 million South Africans.

The unit consists of nine orthopaedic specialists (including the head of department) and 20 residents who provide a full tertiary service as well as a significant portion of primary and secondary care (orthopaedic specialist to patient ratio = 1:344 444).

What was the situation in 2016 as regards emergency orthopaedic care at Tygerberg Hospital?

1. Orthopaedic emergency cases presenting as emergencies: 1214/ month or 40/day on average.

2. Polytrauma patients: an average of 26/month.

3. Open fractures (excluding gunshots): an average of 42/month.

4. Orthopaedic-related gunshot injuries requiring surgery: an average of 68/month.

5. Major orthopaedic emergency surgical cases performed: an average of 620/month or 20/day.

6. Patients awaiting major emergency orthopaedic surgical procedures on any given day: an average of 43/day.

7. Highest number of patients awaiting major orthopaedic surgery on any given day: 73.

8. Open tibia fractures, admission to first debridement: an average of 60 hours.

9. Insufficiency hip fractures, admission to definitive operative time: an average of seven days.

This scenario is not unique in South Africa as most orthopaedic units experience very high overload of their emergency services.

However, our healthcare system, and especially orthopaedics, is definitely not only gloom and doom. Even faced with numerous challenges, the quality of services provided generally remains of an extremely high

standard. Often our methods must be somewhat innovative but expected outcomes are mostly achieved. I frequently refer to orthopaedics in South Africa as ‘Second World Orthopaedics’, that is, ‘First World’ expertise that often has to function in a ‘Third World’ environment. Due to the delay in presentation and/or lack of theatre time, we are often forced to adapt accepted standards of practice. Examples of this would be utilising circular fixation for open tibia fractures that wait an extended period of time before initial debridement or fixator-assisted closure of the wound due to restricted access to services that offer flap coverage.

Another interesting factor in South African orthopaedic care is that the current gold standard of care is not always appropriate in our circumstances. A Taylor spatial frame is an exceptional modality for the correction of severe deformities, but is simply not an option for a patient who is illiterate, has no running water, lives 200 kilometres from the nearest town and has no access to regular public transport. This should be seen as a positive because we learn to make a plan and innovate.

The recent emerging trend is to embrace our unique burden of disease profile, especially with regards to trauma and emergencies, HIV/AIDS and tuberculosis. The average South African orthopaedic specialist is highly experienced in these fields and we are slowly claiming our place in the international arena.

The pre- and post-graduate training programmes for medical doctors, and especially orthopaedic surgeons, are extremely robust and we are very proud of them. Being exposed to such a large amount of trauma surgical procedures is an immensely valuable training tool. South African doctors are known to be hard-working, well-trained, very experienced in their field, surgically competent and able to adjust to very taxing circumstances.

Orthopaedics in South Africa has thus far been blessed with the ability to use the appropriate consumables for the appropriate fracture, injury or condition.

In the past, research has proven to be our Achilles heel. Simply stated, the typical South African orthopaedic surgeon possesses the necessary expertise and performs high-quality clinical work, but is seldom able to convert his or her efforts into any form of research or publication.

Recent emphasis on structured research support in tertiary institutions, in addition to performing research on our burden of disease profile, has seen a significant turnaround in local as well as international peerreviewed publications. There has been a recent increase in researchrelated qualifications by orthopaedic surgeons in South Africa, as well as a rapid increase in the number of specialists registering for, and completing, their PhDs. We offer extensive orthopaedic outreach programmes to sub-Saharan Africa and the government is actively involved in programmes aimed at reducing the neonatal death rate, tuberculosis and HIV transmission, alcohol abuse and trauma. Several successful programmes have also being initiated to improve the treatment of tuberculosis and HIV. Numerous facilities have successfully launched highly sought-after international fellowships in trauma orthopaedics, affording South Africans the opportunity to share their vast experience in this field with their overseas, and African, counterparts.

The quality of health care in certain pockets of the public and private healthcare sector is as good as anywhere else in the world, with state-ofthe-art facilities, excellent specialists and a wide range of treatment modalities freely available.

Innovative processes have blossomed in response to the need to address service delivery overload, adapting lean management principles and overcoming severe inefficiencies.

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Everyday orthopaedic practice in our beautiful country can be excruciatingly frustrating, tiring and exceptionally challenging, but also extremely satisfying, incredibly fluid and varied beyond belief, while allowing for groundbreaking innovation and ‘out-of-the-box’ thinking.

Somehow, 700 Orthopaedic surgeons manage to serve and support 55 million people, and will continue to do so for years to come.

4. Ataguba J. Health financing and NHI in South Africa:why do we need a reform? 2017; www.hstconference2016.org.za/sites/default/files/downloads/ presentation_04-05-2016.pdf (date last accessed 12 September 2017).

5. OECD. OECD Health Statistics 2014 How does South Africa compare? 2017 http://www.oecd.org/els/health-systems/Briefing-Note-SOUTH-AFRICA-2014. pdf (date last accessed 12 September 2017).

References 1. Pillay-van Wyk V, Msemburi W, Laubscher R, et al. Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study. Lancet Glob Health 2016;4:e642-53.

2. Lopez AD, Murray CC. The global burden of disease, 1990-2020. Nat Med 1998;4:1241-1243.

3. Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: historical roots of current public health challenges. Lancet 2009;374:817-834.

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Professor Jacques du Toit, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa jdtt@sun.ac.za

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Current concepts

J. Witt

Current opinion in conservative hip surgery

otal hip arthroplasty has been markedly successful in alleviating hip pain. Consequently, historical techniques, such as re-alignment osteotomies of the femur, have fallen out of favour.1-4 Morphological hip abnormalities have long been recognised as contributing to the development of hip osteoarthritis (OA). There are a number of descriptions in the literature that document methods of addressing these abnormalities.5-9 One of the principal intrinsic difficul-

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ties has been to gain adequate access to both sides of the hip joint without the risk of causing avascular necrosis. The work by Ganz and others,10-15 which revisited the vascular anatomy of the femoral head and applied that knowledge to a safe surgical technique, led to a greater understanding of the mechanism of injury to the hip joint.16-18 This shifted the focus from treating the arthritic hip to concentrating on methods of managing the young patient with a painful hip but without radiological evidence of osteoarthritis.

The impingement concept put forward by Ganz and his co-workers explained how injury to the articular cartilage injury develops and progresses;16,17 this allowed the development of a rational approach to the management of this condition. Femoroacetabular impingement (FAI) and hip dysplasia are now recognised as factors that make a significant contribution to the development of OA.16,17

Femoroacetabular impingement Two main types of impingement are described.

Perhaps the easier to recognise is related to the so-called pistol-grip deformity, which causes cam impingement. Impingement can also occur when the primary abnormality is on the acetabular side, in such cases as acetabular ­retroversion, coxa profunda or protrusio; this is referred to as pincer impingement. The two mechanisms of injury differ.

In cases of cam deformity (Fig. 1), the aspherical portion of the femoral head or head/ neck junction causes a split in the chondrolabral junction as it is forcibly rotated into the

acetabulum during movement of the hip. With repeated impingement, progressive articular cartilage delamination occurs as a precursor to the development of OA (Fig. 2).

In pincer impingement, the mechanism is different: the neck of the femur repeatedly abuts the rim of the acetabulum, causing localised injury to the labrum. In time, reactive changes occur within the labrum, resulting in ossification and increasing coverage of the femoral head. Reciprocal changes can be seen on the femoral neck with indentation and reactive ­callus formation. The injury to the articular cartilage of the acetabulum tends to be less prominent and occurs over a longer period of time.

Leverage of the femoral neck on the front of the acetabulum produces a contrecoup injury to the articular cartilage of the posteroinferior portion of the acetabulum.19 It is rare for there to be only one form of impingement present in an individual; usually, it is of mixed type with one type predominating.

The hip becomes painful because the injured labrum contains nociceptive nerve endings.

The two basic types of impingement occur in somewhat different populations. Symptoms of pincer impingement develop mainly in women aged between 30 and 40, and are often initiated by starting new activities such as yoga or aerobic exercise classes. Cam impingement is more common in athletic males and usually presents a decade earlier. Often, patients present with a history of recurrent groin strain, making it increasingly difficult for them to pursue their sporting activities.

Treatment A conservative treatment programme involves activity modification, the use of non-steroidal anti-inflammatories and physiotherapy. This may be less effective in patients with a significant cam-type deformity who are trying to continue with their usual level of activity. In patients with persistent symptoms, surgery should be considered after appropriate investigation with plain radiographs, MRI and CT scans with 3D reconstructions. Treatment aims to correct the intraarticular injury and underlying ­ morphological

Fig. 1 From top: cam deformity before correction; post-operative radiograph after correction; and cam deformity.

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BJJ News | I ssue 12 | D ecember 2017

complication rates and predictable outcomes.

Key factors in the determination of the outcome are the degree of OA; Tonnis grades 0 or 1 have the best outcomes. Tonnis grade 2 and older age (> 40) are associated with less good longterm outcomes.

Hip joint preservation surgery

Fig. 3 Left acetabular dysplasia.

Fig. 2 Delamination of the articular cartilage. abnormality; this is essential to avoid recurrence of symptoms and further damage to the joint.

The technique of surgical hip dislocation was developed to address these abnormalities.18 It involves a trochanteric flip osteotomy with wide exposure of the acetabulum and femoral head, which allows access to the rim of the acetabulum and head of the femur. A number of reports in the literature have reported the success of this procedure, including allowing patients to return to high-level sport.20-22

Hip arthroscopy The trochanteric flip osteotomy is a significant open operation. Over the past ten years, techniques of hip arthroscopy have progressed markedly. Although hip arthroscopy has been undertaken for many years and has been reported as addressing labral pathology and intra-articular abnormalities,23-25 the description of the intra-articular changes associated with FAI led to the development of arthroscopic techniques to address these abnormalities. The long learning curve associated with hip arthroscopy is well documented.26,27 Those who carry out hip arthroscopy must have the skills to deal with all the morphological abnormalities associated with FAI. Given that many patients with FAI have evidence of mixed impingement, it is important to be able to deal with cam deformities by correcting femoral head asphericity, as well as being able to recess the acetabular rim and repair the labrum. Arthroscopic surgery must be able to achieve the same results as open surgery; this is now the expected standard of care. Failures of arthroscopic surgery are usually related to the presence of residual FAI, too much degenerative change and the presence of unrecognised acetabular dysplasia (Fig. 3).28-30 Recognising which types of hip condition are best managed by arthroscopic intervention and

8

which are best managed by osteotomy is clearly an essential part of assessing a patient and not easily learned without appropriate fellowship training.

Residual developmental dysplasia of the hip Acetabular dysplasia presenting in the adult is still easily missed. Patients frequently give a long history of hip symptoms that have become increasingly debilitating. The classic symptom complex of activity-related groin pain, episodes of locking and giving way with increased residual pain is referred to as the acetabular rim syndrome.31 The pathomechanical feature is the tearing of the labrum with inside-out failure, sometimes with a flap of articular cartilage attached to it. This further destabilises the hip; rim overload leads to progressive chondral changes and the development of osteoarthritis.

The importance of diagnosing this as a cause of hip pain is that judicious intervention is now recognised as being very effective in both improving symptoms and delaying the development of osteoarthritis. Intervention is less effective once significant OA changes have developed.

Surgical techniques aimed at preserving the hip joint and our understanding of the causes of injury have progressed greatly over the past ten to 15 years. These techniques have been extended to revisit the concept of more anatomical correction in slipped capital femoral epiphysis, and for major corrections to address the deformity of residual Perthes’ disease.35,36 Despite the great success of total hip arthroplasty, the failure rate in young patients remains a cause for concern.37 Recognising the clinical and radiological features of a hip of abnormal morphology that is starting to become damaged is essential for all those seeing musculo-skeletal patients both in primary and secondary care. Timely intervention can make a major difference to a patient’s quality of life, and can delay the onset of OA so that the ultimate option of a hip arthroplasty will stand a much greater chance of producing a longlasting outcome.

References 1. Muller ME. Manual of internal fixation. Berlin, Heidelberg, New York: Springer, 1977.

2. McMurray TP. Osteoarthritis of the hip joint.

J Bone Joint Surg 1939;21:1-11.

3. Morscher E. The intertrochanteric osteotomy for osteoarthritis if the hip: analysis of 2251 cases. Bern, Stuttgart, Wien: Huber, 1971.

Management

4. D’Souza SR, Sadiq S, New AM, Northmore-

The principle of treatment is to improve coverage of the femoral head by the acetabulum, thereby increasing the area for load transmission. In the presence of a congruent hip joint, re-orientation procedures involving a triple osteotomy, spherical osteotomy or periacetabular osteotomy (PAO) are the preferred surgical options. If the joint is not congruent, an augmentation procedure, such as a Chiari or shelf operation, may be considered.

In English-speaking countries, the Bernese periacetabular osteotomy (PAO) has become the most commonly used technique for re-­ orientating the acetabulum.21 This technique corrects both dysplasia and version abnormalities of the acetabulum.32 The procedure was developed through a Smith–Petersen approach; recent advances rely on less invasive methods of performing the procedure,33,34 and have low

Ball MD. Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip. J Bone Joint Surg [Am] 1998;80-A:1428-1438.

5. Murray RO. The aetiology of primary osteoarthritis of the hip. Br J Radiol 1965;38:810-824.

6. Solomon

L.

Geographical

and

anatomi-

cal patterns of osteoarthritis. Br J Rheumatol 1984;23:177-180.

7. Harris WH. Etiology of osteoarthritis of the hip.

Clin Orthop Relat Res 1986;213:20-33.

8. Stulberg SD. Unrecognized childhood hip disease: a major cause of idiopathic osteoarthritis of the hip. In: Cordell LD, Harris WH, Ramsey PL, McEwen GD, eds. The hip: proceedings of the third open scientific meeting of the hip society. St Louis: CV Mosby, 1975:212–228.

9. Goodman DA, Feighan JE, Smith AD, et al. Subclinical slipped capital femoral epiphysis.

BJJ News | I ssue 12 | D ecember 2017 Relationship to osteoarthrosis of the hip. J Bone Joint

the acetabular cartilage: femoroacetabular impinge-

30. Bogunovic L, Gottlieb M, Pashos G, Baca

Surg [Am] 1997;79-A:1489-1497.

ment as a cause of early osteoarthritis of the hip.

G, Clohisy JC. Why do hip arthroscopy procedures

10. Chung SM. The arterial supply of the develop-

J Bone Joint Surg [Br] 2005;87-B:1012-1018.

fail? Clin Orthop Relat Res 2013;471:2523-2529.

ing proximal end of the human femur. J Bone Joint

20. Espinosa N, Rothenfluh DA, Beck M,

31. Klaue K, Durnin CW, Ganz R. The acetabular

Surg [Am] 1976;58-A:961-970.

Ganz R, Leunig M. Treatment of femoro-acetabu-

rim syndrome. A clinical presentation of dysplasia

11. Crock HV. The blood supply of the lower limb

lar impingement: preliminary results of labral refixa-

of the hip. J Bone Joint Surg [Br] 1991;73-B:423-429.

bones in man (descriptive and applied). Edinburgh:

tion. J Bone Joint Surg [Am] 2006;88-A:925-935.

32. Ganz R, Klaue K, Vinh TS, Mast JW. A new

E&S Livingstone, 1967.

21. Clohisy JC, St John LC, Schutz AL. Surgical

periacetabular osteotomy for the treatment of hip

12. Judet J, Judet R, Lagrange J, Dunoyer

treatment of femoroacetabular impingement: a

dysplasias. Technique and preliminary results. Clin

J. A study of the arterial vascularization of the

systematic review of the literature. Clin Orthop Relat

Orthop Relat Res 1988;232:26-36.

femoral neck in the adult. J Bone Joint Surg [Am]

Res 2010;468:555-564.

33. Troelsen A, Elmengaard B, Søballe K. A

1955;37-A:663-680.

22.

Peters

JA. Treatment of

new minimally invasive transsartorial approach for

13. Sevitt S, Thompson RG. The distribu-

­femoro-acetabular impingement with surgical dis-

periacetabular osteotomy. J Bone Joint Surg [Am]

tion and anastomoses of arteries supplying the

location and débridement in young adults. J Bone

2008;90-A:493-498.

head and neck of the femur. J Bone Joint Surg [Br]

Joint Surg [Am] 2006;88-A:1735-1741.

34. Khan OH, Malviya A, Subramanian P,

1965;47-B:560-573.

23. Byrd JW, Jones KS. Prospective analysis of

Agolley D, Witt JD. Minimally invasive periace-

14. Trueta J, Harrison MH. The normal vascular

hip arthroscopy with 2-year follow-up. Arthroscopy

tabular osteotomy using a modified Smith-Petersen

anatomy of the femoral head in adult man. J Bone

2000;16:578-587.

approach: technique and early outcomes. Bone

Joint Surg [Br] 1953;35-B:442-461.

24. Byrd JW. Hip arthroscopy: surgical indica-

Joint J 2017;99-B:22-28.

15. Gautier E, Ganz K, Krügel N, Gill T, Ganz

tions. Arthroscopy 2006;22:1260-1262.

35. Massè A, Aprato A, Grappiolo G, et al.

R. Anatomy of the medial femoral circumflex artery

25. McCarthy JC, Lee J. Hip arthroscopy: indi-

Surgical hip dislocation for anatomic reorientation

and its surgical implications. J Bone Joint Surg [Br]

cations and technical pearls. Clin Orthop Relat Res

of slipped capital femoral epiphysis: preliminary

2000;82-B:679-683.

2005;441:180-187.

results. Hip Int 2012;22:137-144.

16. Ganz R, Leunig M, Leunig-Ganz K, Harris

26. Khanduja V, Villar RN. Arthroscopic surgery

36. Ganz R, Huff TW, Leunig M. Extended

WH. The etiology of osteoarthritis of the hip: an

of the hip: current concepts and recent advances. J

retinacular soft-tissue flap for intra-articular hip sur-

integrated mechanical concept. Clin Orthop Relat

Bone Joint Surg [Br] 2006;88-B:1557-1566.

gery: surgical technique, indications, and results of

Res 2008;466:264-272.

27. Griffin DR, Villar RN. Complications of

application. Instr Course Lect 2009;58:241-255.

arthroscopy of the hip. J Bone Joint Surg [Br]

37. Kärrholm J, Garellick G, Rogmark C,

1999;81-B:604-606.

Herberts P. Swedish Hip Arthroplasty Register:

osteoarthritis of the hip. Clin Orthop Relat Res

28. Saadat E, Martin SD, Thornhill TS, et al.

Annual Report 2007. http://www.shpr.se (date last

2003;417:112-120.

Factors associated with the failure of surgical treat-

accessed 06 October 2017). (in Swedish)

18. Ganz R, Gill TJ, Gautier E, et al. Surgical

ment for femoroacetabular impingement: review of

dislocation of the adult hip a technique with full

the literature. Am J Sports Med 2014;42:1487-1495.

access to the femoral head and acetabulum with-

29. Ross JR, Larson CM, Adeoye O, Kelly

out the risk of avascular necrosis. J Bone Joint Surg

BT, Bedi A. Residual deformity is the most com-

[Br] 2001;83-B:1119-1124.

mon reason for revision hip arthroscopy: a

19. Beck M, Kalhor M, Leunig M, Ganz R. Hip

­three-dimensional CT study. Clin Orthop Relat Res

morphology influences the pattern of damage to

2015;473:1388-1395.

17.

Ganz

R,

Parvizi

Femoroacetabular

J,

Beck

impingement:

M, a

et al.

cause

for

CL,

Erickson

A uthor

details

Johan Witt, MBBS FRCS(Orth), Consultant Orthopaedic Surgeon, University College London Hospitals, London, UK johan.witt@sky.com

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BJJ News | I ssue 12 | D ecember 2017

Medico-legal

When the tail wags the dog in medico-legal practice

any orthopaedic surgeons are involved in medico-legal practice.

Some are involved either directly or via agencies through the Medco portal. However, the great majority of reports through Medco have, to my knowledge, been provided by general practitioners and physiotherapists. This is probably related to the (relatively) low levels of remuneration offered for these reports in low-value claims, particularly by the time the agency has taken its cut.

More commonly, orthopaedic surgeons are involved in providing reports in higher value or more contentious personal injury claims, or in claims alleging medical negligence. It is in the former that the author has noted an increasing tendency for the investigation and clinical management of the claimant/patient to be driven by the legal process without any significant involvement from the GP or the NHS. A typical scenario is for the claimant/patient to be referred at an early stage for physiotherapy that is funded by the insurance company. In truth, it is not easy to criticise this given the relative difficulties in accessing physiotherapy treatment through the NHS in many parts of the United Kingdom. The GP notes often contain an entry indicating that there is, “physio through insurance”. On occasions there is a report/­ summary from the physiotherapy clinic, sometimes not.

The next significant event in the claim (investigation/treatment) is the visit to the GP/physiotherapy expert for the initial medical report. If the symptoms are improving/settling and a view is taken by the expert that this is a “six-month case” then there is no major problem and no need to trouble the GP or NHS in any event.

However, if symptoms persist despite physiotherapy and are still posing significant problems, the next suggestion is usually an MRI scan and orthopaedic opinion as the case is beginning to stray outside the expertise of the provider of the first report. The MRI is usually requested by the author of the first report without any input from, or dialogue with, the GP, who frequently has little or no idea what is happening.

The claimant/patient then arrives in the consulting room of the orthopaedic expert, who

M

10

reviews the history, treatment records and MRI scan, examines the claimant/patient and provides his opinion on causation, condition and prognosis. Most orthopaedic experts will give a view to the effect that, “If I was treating claimant X I would organise………” if this is likely to influence the prognosis and hence the level of compensation that the claimant will receive.

This might be more physiotherapy, a different scan, an opinion from someone with a different orthopaedic sub-speciality or a different speciality altogether (Pain, Rheumatology, Psychiatry etc). The report will then usually find its way back to the claimant/patient for comment/ approval. If the recommendation is for more (or different) therapy or a new scan (different type or different area) this will usually (again) be organised by the solicitor/insurer without GP/ NHS involvement.

If the recommendation for other specialist opinion is to determine whether the injury that was the subject of the claim had caused the requirement for the surgery or other therapy, or for clarification of issues concerning causation or prognosis, the solicitor/insurer will organise it. If it is to do with treatment that may ultimately alter the prognosis then there is a potential problem. The claimant/patient can go to the GP armed with his expert report and request a referral for the recommended opinion or the referral can be made through the private sector via the network of contacts that the orthopaedic expert or the claimants’ solicitor has.

It is the latter situation that I seem to be encountering increasingly frequently. In a recent personal injury case I reviewed a claimant who had undergone spinal surgery. There was a fundamental issue of causation as to whether the injury that was the subject of the claim had caused the condition that required surgical intervention. When going through the reports and the available medical records it became clear that the referral to the spinal surgeon had been recommended by the orthopaedic expert (a non-spinal surgeon). There was nothing in the GP records to show that such a referral had been made. Prior to the surgery there were nerve blocks/interventions. Again

M. A. Foy

there was nothing to reflect this in the GP records (poor practice on behalf of the treating consultant). The first reference in the GP records was the summary after the operation when the patient arrived for wound check and suture removal. This is not an isolated case.

When talking to claimants it is quite common to hear, regarding investigation and treatment, “Oh my solicitor organised all that, I didn’t need to see my GP.” Equally, when looking through GP records it is not uncommon to see entries, “seeing Harley Street specialist” or “investigation and treatment being organised by insurers after accident”. The claimant assumes that the events within the litigation process are a routine part of their investigation and treatment. On the other side of the coin, it is also clear from reading the GP records that many doctors misunderstand the nature of the medico-legal claims process. It is not unusual for a GP to abrogate responsibility for further investigation or treatment because their patient is seeing an orthopaedic specialist who they assume is providing advice on investigation and treatment when in fact the report deals

BJJ News | I ssue 12 | D ecember 2017

primarily with causation and is for use in the claim and ultimately for the court.

This all seems to detract from the traditional practice of medicine that we were taught at medical school where the GP is the gatekeeper and focus for patient care and everything flows through him. We now have solicitors in certain areas bypassing the GP altogether. Obviously the traditional doctor/patient relationship that existed previously has changed considerably.

Patients complain about rarely seeing the same doctor, difficulties getting appointments and lack of out-of-hours cover.

Does it all matter? What can/should we learn from it? My view is that we need greater clarity

and closer dialogue between orthopaedic experts, solicitors and the doctors who are responsible for the claimants/patients day to day care. In the claims procedure, solicitors need to make it absolutely clear at the outset that the default position is that the report is for use in the legal case and is not a direct part of their clients’ clinical management. Experts need to reinforce this view when they interview and examine claimants. They need to make it clear that it will be necessary to discuss plans for ongoing investigation or treatment with their GP or hospital specialist. It is obviously important that claimants/ patients do not have unnecessary duplication of scans and other radiological investigations.

In the same way that we separate our role as expert witnesses (responsibility to the court) from our role as clinicians (responsibility to the patient), we need to ensure that within our expert witness role, as far as we are able, any comments or recommendations for investigation or treatment are relayed to the claimant’s general practice. We should aim to prevent the legal tail from wagging the medical dog.

A uthor

details

Michael Foy, FRCS foyfrcs5@gmail.com

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History

J. Kirkup

One hundred years of surgery using stainless steel

ignificant surgical instruments are identified in archaeological material of the Roman Empire, mainly from the first to sixth centuries AD, when bronze, an alloy of copper and tin, was the principal metal; fortunately, bronze resists destructive corrosion enabling the survival of many instruments. Importantly, Roman scalpels had iron/steel knife blades, although these are usually totally absent or only found rarely as rusted remnants. A few heavy Roman iron cauteries have survived but are always severely corroded.1

S

Decline of the Roman Empire coincided with the disappearance of bronze instruments as cheaper poor-grade iron/steel replacements evolved. Except for a few larger items, surviving instruments are rare because of ferrous corrosion, until 1000 years later in the 16th century, by which time better steels had been developed.

This hiatus reflects the lack of furnace temperatures of a sufficient level to liquefy the metal uniformly. Manufacture involved beating iron/steel into layers to produce bulky and clumsy items that were vulnerable to corrosion.

Considerable progress was made when Benjamin Huntsman, a watch-maker in Doncaster, produced cast steel in about 1750 in crucible containers capable of higher temperatures than hitherto,2 enabling later application to the manufacture of lighter and more elegant instruments. Yet rusting remained a problem until the later 19th century, when it was solved by nickel and chrome plating of cast steel. Initially, such instruments had organic handles made of ebony, ivory or tortoiseshell until in the 1880s, sterilisation by boiling or flaming rendered organic materials loose and useless. All-steel items evolved, protected by nickel plating. This was often applied as a single layer in the United Kingdom, which resulted in rusting at the pivots of forceps and scissors, expensive repairs and re-plating.

It is now accepted that the introduction of stainless steel was due to Harry Brearley (18711948) (Fig. 1), metallurgist of Sheffield in 1913,3 initially to prevent damage to the rifling of gunbarrels, and then for the manufacture of domestic cutlery. Earlier discoverers are claimed by

12

Fig. 2 Charles Heath, otologist.

Fig. 1 Harry Brearley, metallurgist.

Fig. 3 Heath’s first stainless steel instruments, for mastoid surgery. Note that A and C have attached ‘lifters’ to elevate the handles on flat surfaces and to assist picking them up more readily – it seems this addition was not copied!

some, although none led to any productive process.4 In early 1916, Charles Heath FRCS (18561934) (Fig. 2), an aural surgeon of London, mooted the application of stainless steel to surgical instruments and engaged the interest of Mayer and Company of London, specialists in otolaryngology instruments. Their production of several rustless steel instruments favoured by Heath was published in early 1917 (Fig. 3).5 Unfortunately, this early form of stainless steel was found unsuitable for sharp blades. Mayer

and Company wrote in their 1931 catalogue: “At present we cannot recommend scalpels or other knives of stainless steel – no doubt as improvements are made they will be produced – but scissors have proved very satisfactory …

Generally speaking the cost is about 30% to 50% higher when made in this material … than those made of carbon steel, the advance being due to the extra cost of metal, the increased work entailed in forging and filing, and the wastage due to these difficulties.”6

BJJ News | I ssue 12 | D ecember 2017

noted that “higher initial cost is more than offset by the fact that the instruments are practically indestructible, require less repairs and no replating; they maintain their clean and bright appearance with a minimum of labour compared with carbon steel, and by their length of service have rightly earned the reputation as an economical proposition”.7 Similarly, Down

Fig. 4 Periosteal elevator (2/3 scale) of early stainless steel maintained sharp by repeat grinding, losing one inch in 50 years.

As the replacement of stainless steel proved costly, its early introduction was slow. Meanwhile, scalpel blades continued to be manufactured in carbon steel, a better metal for sharp blades, which in practice were used once before being discarded. By contrast, in the United States of America, carbon steel blades were replaced by the new alloy. In 1930, Allen and Hanbury of London, surgical instrument makers, reported “their adoption of stainless steel as a standard material for practically their entire range of non-cutting instruments”.7 They also

Bros., in their catalogue of 1929, emphasised these features, suggesting that stainless steel had great advantages in a humid climate while excluding instruments with cutting edges, lithotrites and the spring-arched blades of gastric clamps, which were liable to snap.8 An example of early stainless steel losing an edge is shown by a periosteal elevator used in one theatre for 50 years (Fig. 4).

In France there was hesitation in accepting the new steel, especially by the important manufacturer Collin as late as 1935, for Collin enjoyed a high reputation for fine-quality nickel and chrome plating, emphasised in their meticulous production of ‘take-apart’ pivoting instruments, which necessitated double plating to protect the articulation. By contrast, Rainal, another Parisian manufacturer, emphasised the benefits of the new steel, termed ‘Inox’, in their 1934 catalogue; by 1939, stainless steel was recognised for its practical advantages worldwide.9 The stainless steel of 1913 was subject to continuous investigation by metallurgists: in 1991 the International Standards Office, backed by the British Standards Institute, published 16 precise chemical formulae for the manufacture of stainless surgical instruments.10 These were divided into Martensitic, Ferritic and Austenitic steels, the differences determined principally by variable quantities of chromium, molybdenum and nickel to offer springiness for curved suture needles or intestinal clamps but stability for bone cutters and fracture plates.

Continuous refinement of stainless steel led eventually to its use for orthopaedic prostheses, most significantly for the femoral portion of the Charnley low friction arthroplasty. Despite this,

certain applications of stainless steel are now replaced by plastics, chrome-cobalt, titanium and other materials.

References 1. Jackson R. Doctors and Diseases in the Roman Empire. London: British Museum, 1988:112-118.

2. Derry TK, Williams TI. A Short History of Technology: From the Earliest Times to A.D. 1900.

Oxford: Clarendon Press, 1960:480-481.

3. Brearley H. Harry Brearley, Stainless Pioneer: Autobiographical Notes. Sheffield: British Steel Stainless, 1989.

4. No authors listed. Penn Stainless Products, Inc. The History of Stainless Steel. http://www. pennstainless.com/blog/2012/08/the-history-ofstainless-steel (date last accessed 04 October 2017).

5. Heath CJ. Non-rusting steel and other instruments. Medical Press. 21 January 1917, 76-77.

6. Mayer and Phelps. Catalogue of Surgical Instruments and Appliances. London: Mayer and Phelps, 1931:iii-vii.

7. Allen & Hanburys Ltd. A Reference List of Surgical Instruments and Medical Appliances, London: Allen & Hanburys Ltd, 1930.

8. Down Bros Ltd. A Catalogue of Surgical Instruments and Appliances. London: Down Bros, 1929.

9. Kirkup J. The Evolution of Surgical Instruments.

Novato, California: historyofscience.com, 2006:121.

10.

No

authors

listed.

British

Standards

Institution. Stainless Steel for Surgical Instruments Milton Keynes, BSO 5194: Part 1:1991 and ISO 7153-1:1991 (E), 1991.

A uthor

details

John Kirkup, MBE, MD, FRCS, Dip Hist Med, Curator of Historical Instrument collection, Royal College of Surgeons of England and author of The Evolution of Surgical Instruments. john.kirkup@doctors.org.uk

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Art

J. Scott

Kenneth Armitage and the Arts Project at the Chelsea and Westminster Hospital

was a medical student at the Middlesex Hospital in London in the mid-1960s and lived in a large basement flat with four flatmates off the Fulham Road, in West London. Our local hospital was St Stephen’s, which had been a large Victorian workhouse.

There were museum charges in those days but the Tate was free on Sundays, so we often used to visit it and have lunch in a pub nearby. I remember visiting an open-air sculpture exhibition just across the river in Battersea Park on one such morning and I particularly liked a rather strange piece that was about six feet high and two feet wide. It had two funnels pointing out forwards from its upper aspect. The bronze was flat and slightly textured and there were narrow transverse ridges (Fig. 1). Although basically abstract, it seemed to have figurative connotations. One imagined noises or voices coming from the trumpet-like funnels.

It was called Pandarus and was by a sculptor called Kenneth Armitage, of whom I had not heard.

I often thought vaguely about this sculpture over the years, and I read a little about Armitage. I discovered, for instance, that he had represented the United Kingdom at the Venice Biennales in 1952 and 1958. I learned that Pandarus was a soldier who in Homer’s Iliad fights on the side of Troy in the Trojan Wars, and was used by Chaucer as a go-between in Troilus’ affair with Cressyde.

By an odd coincidence, I became a consultant at St Stephen’s Hospital and as chairman of the medical staff committee I was able to introduce a small Arts Project in the early 1980s. At the back of the hospital, in the Victorian part, there was a very long dark gloomy corridor running the length of the hospital, which was extensively enlivened by students from the Royal College of Art. With the help of Hugh Casson, who lived nearby and was Provost of the Royal College, we arranged an extremely successful public competition for a mural to decorate the front hall.

We were able to continue this when St Stephen’s was replaced by the new Chelsea and Westminster Hospital, which opened in 1993.

I

14

Fig. 1

Many of the most influential contemporary artists seemed to be our patients. We were also lucky to be extensively helped by Roger de Grey, who was President of the Royal Academy and Peter (later Lord) Palumbo, who was chairman of the Arts Council and became chairman of our fundraising activities. Our efforts were greatly encouraged by Sir Richard Attenborough, who was a Vice President of Chelsea Football Club and had a particular interest in twentieth-century British painting. He had been responsible, in 1985, for the Attenborough Report, which evaluated the accessibility of the arts for people with disabilities.

There are large atrial spaces and open shelves in the new hospital, which seemed very suitable for large works. We got off to a good start with The Acrobat in steel, measuring 65 foot high, by Allen Jones (Fig. 2), and three silk banners by Patrick Heron (Fig. 3). A little later, Edouardo Paolozzi made us a donation box for the front hall (Fig. 4).

I found out that Kenneth Armitage still worked from a studio in Olympia and engineered a meeting through a mutual friend. Kenneth and I became friends and I visited him several times in his studio (Figs 5 and 6). In

Fig. 2

Fig. 3

1996, he had a large retrospective exhibition at the Yorkshire Sculpture Park to mark his 80th birthday. It was opened by Lord Gowrie and was a tremendous success. It had been due to

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Fig. 7

Fig. 6 Fig. 4

Fig. 5 close in the autumn but was extended until April 1997.

When the time came for the exhibition to be taken down and the pieces were to be returned to the collectors and galleries from whence they had come, I asked Kenneth if by any chance we could borrow a piece for the hospital. “How

many would you like?” he replied. So, by wonderful good fortune, we were able to borrow four pieces (Fig. 7). We had them for about two years, during which time I was able to visit Pandarus, which I had initially seen in the park, each morning when I arrived in the hospital. Kenneth was anxious that we should buy it and offered it to the hospital at a much reduced price but I was sadly unable to raise the money. Eventually it was returned to a commercial gallery and sold for an extremely handsome price.

A few years later, the owner of a leading Gallery in the West End of London showed me, on his laptop, the image of a relief sculpture. The image had been sent to him from the United States. He asked me if I recognised it. “Apparently, it’s by your friend Armitage”, he said. I said that the trouble with Kenneth was that, unlike his contemporaries, there was no book containing images of all the sculptures that he had made. He suggested that as I was just about to stop work as editor of The Journal of Bone and Joint Surgery (British Volume), which I was – this being autumn 2012 – I should do it.

Kenneth’s estate is extremely successfully looked after by a Foundation, so that, for instance, there is a sculptor-in-residence programme in his wonderful studio. I asked them if they were planning such a book and they suggested that, as I had known him, I should take on the project.

In fact, it was an exciting exercise and relatively easy because several hours of interviews with him had been recorded and are available in the British Library, and his papers and correspondence are in the archive of the Tate Gallery.

I also had the great help of a research assistant from the Sainsbury Centre in Norwich. The task was made even easier and more fun by the fact that several people who had known him well during his early years are still alive and were keen to give a clear account of his life.

So it was published by Lund Humphries and came out last year (2016), when there were exhibitions in Bath and Leeds to mark the centenary of his birth. Antony Gormley kindly wrote the introduction.

We gathered in Kenneth’s studio for the launch and I was able to record that it had all started when a medical student had noticed a strange shape in Battersea Park almost exactly sixty years previously.

Editorial note: James Scott is far too modest to give the full publishing details of his magnum opus. BJJ News is not, so for our more civilised readers they are: The Sculpture of Kenneth Armitage With a Complete Inventory of Works

By James Scott assisted by Claudia Milburn, with an Introduction by Michael Bird and a Foreword by Antony Gormley Lund Humphries 2016 Hardback • 208 Pages • Size: 290 × 240 mm 360 B&W illustrations and 40 colour illustrations ISBN: 9781848221789 £55.00 Available at all good booksellers.

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James Scott, Editor Emeritus, The Bone & Joint Journal j.scott@boneandjoint.org.uk

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BJJN00000038 research-article2017

BJJ News | I ssue 12 | D ecember 2017

Orthopod’s View

A. Ross

Medical writing is becoming more difficult to read: official

ot all those who read The Bone & Joint Journal are aware that every article we publish has been rewritten, usually extensively, by one or more of the primary editors. For the last five years their names have been quietly recorded at the end of each article.

It has gradually become apparent that submitted articles are becoming more difficult to read, not necessarily because of the complexity of the study but because of the increasing number of abbreviations and complex words used to describe it.

This is not, however, a problem that just affects The Bone & Joint Journal. Recently, the national press drew attention to a paper published by the Department of Clinical Neuroscience at the Karolinska Institute in Sweden entitled ‘The readability of scientific texts is decreasing over time’.1 In this, the authors used

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so-called ‘readability formulae’ to review 700 000 abstracts from 123 scientific journals published between 1881 and 2015. While this did not include The Bone & Joint Journal itself, it did include a number of highly cited journals in different disciplines from around the world.

Without going into great detail of the methodology, the fundamental question that the authors were asking was how the readability of the abstract of an article related to its year of publication.

What did they find? First, that the percentage of abstracts that required a postgraduate level of English to make themselves understood had risen from 14% in 1960 to 22% in 2015.

Second, that the readability of abstracts correlated with the number of co-authors, but that this in itself did not fully account for the change seen with time. Third, that general scientific

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jargon had increased, almost certainly as a result of increasing subspecialisation. In summary, therefore, the language used in reporting science overall has become more complex with the passage of time, not only making papers less readable but also, increasingly, denying access to the scientific content to those who were not specialists in the field. This is the essence of ‘jargon’. On the plus side, I was pleased to see that clinical medicine was arguably the best performer. It is the geneticists and molecular biologists who need to be particularly concerned!

The authors quite rightly say that the essence of good scientific reporting is clarity and accuracy. The increasing use of complex words has also helped spawn a glut of abbreviations.

While this limits the repetition of ponderous words and phrases, their proliferation means that by the time one is halfway through a paper and encounters a sentence such as “3% of the patients who had an ECTR and 10% of those who had an OCTR had a poor BSS and BFS on BCTQ”,* one might be forgiven if one’s attention drifts somewhat.

Leaving aside the scientific content for a moment, the best papers are those that can be read by the ‘intelligent layman’. Short words; simple sentences; a logical chronology and clear, concise conclusions. One of the best examples of this is undoubtedly the original description of the structure of DNA by Watson and Crick in a letter to Nature in April 1953.2 In one printed page, they review the relevant literature, explain why they think that previous theories are “unsatisfactory” and describe the double helix structure that is now familiar to all of us (indeed, part of our DNA). The language in which the letter is written is so simple that it

could be understood by a contemporary GCSE student.

There is an undoubted tendency among those writing scientific papers for publication that the use of complex language and jargon makes a paper sound more ‘scientific’. Indeed, the authors of the Karolinska paper describes this as ‘science-ese’, a word that I profoundly hope will not continue to be used in polite society. Nonetheless, their point is well made. It is a tendency strongly to be resisted.

I hope I will be forgiven for repeating the oftforgotten mantra of the great lexicographer HW Fowler: “Prefer the familiar word to the farfetched; prefer the concrete word to the abstract; prefer the single word to the circumlocution; prefer the short word to the long; prefer the Saxon word to the Romance.”3 It would make everyone’s life easier. *Not a genuine quotation, but quite close and deliberately not referenced out of kindness!

References 1. Plavén-Sigray P, Matheson GJ, Schiffler BC, Thompson WH. The readability of scientific texts is decreasing over time. Elife 2017;6:e27725.

2. Watson JD & Crick FHC. A structure for deoxyribose nucleic acid. Nature 1953;171:737-738.

3. Fowler HW. Modern English Usage. Second ed.

Clarendon: Oxford, 1978.

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

BJJN00000039 letter2017

BJJ News | I ssue 12 | D ecember 2017

N. Gittoes

Letter

National Osteoporosis Society Clinical & Scientific Committee Response to Today programme, BBC Health Website and Inside Health coverage of bisphosphonates and osteoporosis The Clinical and Scientific Committee of the National Osteoporosis Society would like to formally register our disappointment with the recent media coverage of a report by Dr Richard Abel et al entitled ‘Long-term effects of bisphosphonate therapy: perforations, microcracks and mechanical properties’.

Following publication of the report in Scientific Reports, a journal from the Nature group, the story was covered on the Today programme, the BBC Health website and BBC Radio 4’s Inside Health.

We are extremely concerned that the findings of this study, highlighted purely because of the use of a new technology, were reported as having potentially harmful effects to patients already receiving bisphosphonate therapy to reduce their increased risk of osteoporosisrelated fractures. Thousands of such patients were let down and misled by the way in which the story was reported.

As a result of the media coverage, the National Osteoporosis Society’s Helpline received a high number of calls from patients who were understandably worried about whether or not they should continue to take their osteoporosis medications.

While it is of course important that patients are made aware of any new research, sensational stories such as this risk putting many off taking prescribed medications without presenting the opportunity to get a full, balanced picture, which would allow patients to make a truly informed decision about their care.

In terms of the specific research findings discussed on the programmes, the observations are of interest but are of questionable significance because the overwhelming evidence is that these agents protect patients from fractures. From a technical standpoint, this is primarily due to in-filling of tiny cavities in the bone, so called resorption pits, a finding that was confirmed in the Abel study.

The use of bisphosphonates, such as alendronate, has been examined in well-designed, placebo-controlled studies comprising over 20 000 patients at increased risk of fracture over the last 20 years. These studies have consistently shown that patients who took bisphosphonates were protected from fractures and broke bones much less often than those given the placebo. This evidence base has been reviewed by and supported by the National Institute For Health and Clinical Excellence.1 In contrast to the extensive, well-researched evidence base showing that bisphosphonates prevent fractures, there are major scientific limitations in Dr Abel’s report, which was based on small bone samples from only 16 people in a non-randomised study, of which only six patients on bisphosphonate treatment were scanned. The preliminary nature of their data was ignored by the BBC in preference for speculation and the major limitations of the study were not even acknowledged, let alone adequately addressed, in any of the coverage. The Abel study certainly does not provide sufficient evidence to change clinical practice.

While news items about osteoporosis in the mainstream media are always a welcome way to raise awareness, a lack of balance was sadly a feature of all of the coverage of Dr Abel’s study.

The media reports did nothing to help those living on a day-to-day basis with the devastating effects of osteoporosis, particularly those patients at highest risk of fracture where the benefits of treatment with bisphosphonates far outweighs the risks.

Reference 1. Freemantle N, Cooper C, Diez-Perez A, et al. Results of indirect and mixed treatment comparison of fracture efficacy for osteoporosis treatments: a meta-analysis. Osteoporos Int 2013;24:209-217.

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Professor Neil Gittoes, Chair, National Osteoporosis Society Clinical and Scientific Committee, and on behalf of the National Osteoporosis Society Clinical and Scientific Committee Members: Professor Juliet Compston, Professor Elaine Dennison, Professor Richard Eastell, Professor Terry O’Neil, Dr Louise Dolan, Miss Alison Doyle, Mrs Jill Griffin, Dr Kassim Javaid, Professor Eugene McCloskey, Dr Nicola Peel, Professor David Reid, Dr Ailsa Welch, Dr Stephen Gallacher, Dr David Armstrong, Dr Stuart Eastman. www.nos.org.uk

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