BJJ News
Formerly known as JBJS (Br)
BJJ News | I ssue 3 | J une 2014
Issue 3
Are you cut out for it? Trainee corner p2
Assessment of operative skills in junior trainees
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Also in this issue: Bridging the gap
Orthopaedic history p4
Orthopaedics in Ukraine M. Greiss
Orthopod’s view p14
A brief history of orthopaedic surgery in New Zealand F. Gilkison
p17
Sculpture and the female form C. R. Weatherley
BJJ News
Issue 3
Journal Office:
Advertising enquires:
Edited by:
22 Buckingham Street, London
Dr Pam Noble
Mr David Jones
WC2N 6ET, UK
ADmedica
Honorar y Consultant Or thopaedic Surgeon, London
bjjnews@boneandjoint.org.uk
pnoble@admedica.co.uk
Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath
June 2014 Editorial 1
Good, bad and ugly news
D. Jones, A. Ross
Trainee corner
2
Are you cut out for it?
D. Jones
14 A brief history of orthopaedic surgery in New Zealand
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F. Gilkison
Bridging the gap Orthopaedics in Ukraine
M.Greiss 6
Orthopaedic history
Orthopod’s view
16 Experience of a Fracture Surgeon
Establishing a Link Between
working in a District General
Addenbrooke’s Hospital, Cambridge
Hospital
and Yangon General Hospital,
Myanmar
17 Sculpture and the female form
D. J. W. Cash, A. R. Norrish and V.
J. Hambidge C. R. Weatherley
Khanduja
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Notes from the road
Letters
19 The Glasgow Fracture Pathway; the right answer to the wrong question
Fellowship Report: Holland Orthopaedic and Arthritic Centre,
Toronto, Canada
20 101 not out! Clifford Brewer: Britain’s oldest surgeon and angle
H. Kazi
12 Evaluation, solutions and innovation in
G. Tait
R. Owen and R. Earlam
complex hip replacements: report on the 2013 Bristol Hip Arthroplasty Course
E. Smith
A Bone & Joint Publicat ion THE BRITISH EDITORIAL SOCIET Y OF BONE AND JOINT SURGERY. Registered charit y no: 209299. All ar t icles within BJJ News are published under the Creat ive Commons Attribut ion License (CC-BY 3.0)
BJJ News
Editorial n the United Kingdom we have a National Health Service the performance of which ranges between excellent and poor. In the same newspaper we may read of great advances in cancer care and groundbreaking operations alongside articles where overseas doctors are being interviewed on Skype to help prop up our failing emergency services without proper evaluation of their competence, and reports elsewhere of patients in hospitals and nursing homes being subjected to cruelty and deprivation. The good news both in orthopaedics and elsewhere in the NHS relates not only to the achievements of those individuals and teams who deliver excellent treatment and advances in health care but also to the agencies which have facilitated their progress, not least the literature through which clinical care, research and teaching initiatives are reported. In this respect, the Bone & Joint brand is up there with the best. Its inclusive philosophy and high editorial standards allow The Bone & Joint Journal, Bone Joint Research and Bone & Joint 360 to present a comprehensive scientific package and we at BJJ News are happy to sit alongside to report other aspects of our orthopaedic world. It is pleasing to note that in the current issue of BJJN, the news is generally good and includes an innovative competition to assess operative skills, examples of charit able work and projects overseas, along with the usual reports of what orthopods get up to both in and out of clinical practice. The bad news in orthopaedics, to a significant extent, stems from increased life expectancy, the expectations of patients and an inability to cope with demand. This is not helped by political meddling and the inappropriate administrative and managerial practices which beset the current NHS. In metaphorical terms, with power shifting away from senior doctors, we think it’s fair to suggest that the non-commisioned, through manipulation of secretarial services, clinics and waiting lists, are bossing the officers. Despite the efforts of senior doctors to maintain standards and the continuity of care it is no wonder many senior doctors lose heart and elect to quit the game. This attitude filters down to the juniors whose morale is also undermined because of regulations which have destroyed the
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firm structure and deprived them of opportunity to gain clinical and operative experience. They are also subject to protocols and procedures which make it difficult to concentrate on the job in hand, which is the direct clinical care of the patient. They may also be marginalised in having first contact with the patient. As an example of where a protocol-driven service is losing the plot, we recenlty came across an indefensible medico-legal case against a hospital in which a trainee triage nurse in an emergency department missed an obvious case of a slipped upper femoral epiphysis, was allowed to discharge the patient without referral and then, because a tick-boxing protocol was followed, was subsequently supported in these actions by the nonmedical lead of the emergency services. Nevertheless, in spite of the system in which junior doctors work, it is always re-assuring to confirm that the great majority of those aspiring to a career in or t hopaedics are hard working, principled and caring. Ugly news occurs when b e n e vo l e n t v a l u e s a n d responsibilities towards those in their care are abandoned by an individual or a group. Although there is no excuse for this behaviour which is sadly reported more frequently, the seeds can be sown through discontent with the system in which health carers find themselves. This is recognised in the wake of the Staffordshire enquiry by emails and notices around hospitals requesting employees to report the actions of others who are failing in their duty of care to patients. It is a sad reflection on the system that such notices are seen to be necessary and let’s hope such a culture can be driven from our hospitals. With regard to how trainee surgeons should conduct themselves, we are aware that in many ways the younger generation doesn’t want to be told by some old codger how good it was in their day. However, with the aim of helping them to avoid being the subjects of bad or ugly news, there is nothing wrong with encouraging them to aspire to clinical excellence and continuity of care to patients, having role models who demand maintainance of standards and fighting against daft regulations which deprive trainees of the time to train and work with their seniors.
Good, bad and ugly news
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BJJ News | I ssue 3 | J une 2014
Trainee corner
D. Jones
Are you cut out for it? David Jones reports on how the brainchild of two trainee surgeons, a Royal College, and an Ancient and Honourable Society co-operated to bring about an innovative surgical skills competition way from orthopaedics, among other interests, I serve as ‘ Master of Awards’ for The Honourable Society of Knights of The Round Table (KORT). This charitable organisation dates from 1720 and champions Arthurian principles, which include support to young people at the beginning of their careers. As examples, for many years, KORT has given financial awards, through their institutions, to musicians, artists, craftspersons and trainee barristers. These young, talented people share the common problem of a shortage of funds in a competitive professional field. With improved resources KORT was in a position to offer an award to The Royal College of Surgeons of England and, following discussion with their Development Office and Senior
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Fig. 1 Excision of a cutaneous tumour
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Vice-President, Mike Horrocks and through the Opportunities in Surgery Department it was decided to inaugurate the Knights of The Round Table Award for Surgical Skills. Each year this would recognise the most technically proficient among Core Surgical Trainees across all specialties. The award would be to the winner of a national surgical skills competition organised on a regional basis, with the final at RCS in London. The prize of £1000 would be an educational bursary to go towards a course or meeting recognised by the RCS. The College was particularly keen to encourage Core Trainees at the beginning of their surgical careers in an environment of uncertainty, great competition and limited study leave budgets. It was relatively easy for the College to move ahead because the seeds of such a competition had already been sown by two trainees, Lilli Cooper and Kathryn Ford, who spotted the potential and likely popularity of such a course. They designed and ran a surgical skills competition for core surgical trainees in London called ‘Are You Cut Out for it?’. The RCS sponsored this competition to become a national franchise and they
produced a franchise document containing all the details of how such a course might be conducted. One of the core principles was that the partipants competed in pairs, alternating between operator and assistant because, just as in normal practice, assistance is required. The judges would not only observe the skills of the operator but also interrogate the assistant on the principles and details of the operation. Working with Jane Roberts of Opprtunities in Surgery at RCS (pcsevents@rcseng.ac.uk) and Nick Gerolemou of ‘Limbs and Things’ (nick .gerolemou@limbsandthings.com) who had kindly donated the equipment and disposables, they invited applications from regional centres, where the heats were conducted between March and September 2013. In the heats the competitors performed a series of simulated surgical techniques such as suturing and laparoscopy. The judges were drawn from local surgeons and trainers and the judging criteria defined in a standardised format to ensure consistency nationwide. In this pilot year the approach was low-key but the system proved workable and acceptable and delivered five regional pairs to the Finals
Fig. 2 Laparoscopic appendicectomy
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Fig. 3 Specimens for f inal scrutiny by the judges
at RCS on 22nd February, 2014 to which I was invited. The concept proved very popular among the trainees as hitherto there had not been an event to recognise their surgical skills. Many of the finalists were interested in orthopaedics and the majority of judges were orthopaedic surgeons. In the finals, all pairs had to undertake three operations; excision of a cutaneous tumour (Fig. 1), debridement and suture of a wound and laparoscopic appendicectomy (Fig. 2). All the specimens were available for final scrutiny by the judges (Fig. 3). The winning two pairs then took part in a tie-break involving simultaneous insertion of a chest drain (Fig. 4) Before that, there had been a tie for second place which was decided by a competition in knot-tying.
Fig. 4 Simultaneous inser tion of a chest drain
The whole day was conducted in an enjoyable way, with competitors, judges and organisers entering fully into the spirit of the event. The winners and runners-up are shown in Fig. 5. In view of the popularity of the competition, KORT doubled its award. The extra £1000 was used to give a £500 prize to the runners-up, gifts to all the finalists and a wine reception to everybody who participated on the day (Fig. 6). As a further recognition of their efforts, Lilli, Kat, Rumina and Mo were invited to a formal dinner of The Knights in The Peers’ Dining Room at The House of Lords, where they were again congratulated and warmly applauded. ‘Are You Cut Out For It’ has three aims: to improve practical skills in a fun environment, encourage cohesion of surgical peers and A uthor
improve interaction with local surgical seniors. There is little doubt that these aims are being fulfilled. It is gratifying that an institution dating from John Hunter’s time can collaborate usefully with the modern RCS and re-assuring that, in spite of all the difficulties which beset them, there is great enthusiasm among Core Trainees, along with examples of how trainees and trainers are prepared to go out of their way to help each other. It is hoped that next year’s competition will arouse even more interest and enthusiasm. The College is happy to answer enquiries and anybody interested in running a region heat in 2014 to compete in the 2015 final, please contact pcsevents@rcseng.ac.uk
details
David Jones Editor, BJJ News davidhajones@hotmail.co.uk
Fig. 5 The winners Rumina Begum and Mohammed Tahir (right), both aspiring or thopaedic surgeons from London, and the runnersup Mr Thusitha Hettiarachchi and Miss Arkeliana Tase (lef t) from the east of England with David Jones.
Fig. 6 All par ticipants at the end of the day
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BJJ News | I ssue 3 | J une 2014
Bridging the gap
M.Greiss
Orthopaedics in Ukraine
Magdi Greiss reports on his visits to the far west of a troubled country.
Fig. 1 Ambulance ser ving the Trauma Unit
es, the Iron Curtain is back! Due to its somewhat unenviable geographical position, the Ukraine is on the edge of Europe and is being subjected to a vicious tugof-war between East and West. This huge country, the largest in Europe, has a chequered history. When the Soviets left in the early 1990’s after the fall of the USSR, they took everything with them, including all the medical equipment down to the last set of screws and plates. As a member of WOC since 1986, I was looking for charitable work nearer home rather than anywhere in Africa or SE Asia, as I was heavily involved in setting up a foot and ankle service in Cumbria, with very little spare time. In the early 90’s, Eastern Europe was just what I was looking for: near enough to travel easily to, and with the potential of making an
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Fig. 2 Lady in out-patients
impact even during short visits. I started in Poland, a country that needed western help having gone through a torrid time after the demise of communism. A decade later, Poland no longer needed a helping hand, especially after joining the EU. The local Cumbrian Rotary Club was already sending obsolete and unwanted hospital equipment to Western Ukraine when I met Brian Early, a key figure in the club. As Kiev was consuming most of the government’s health budget, we looked at an isolated hospital at the foot of the Carpathian range, near the Hungarian border, which had very little help or funding from the central Ukraine government, or indeed anyone else. Uzhgorod was crying out for any form of humanitarian aid. Though the Ukraine project is a designated WOC project, all expenses were either self-funded or partly met by the Rotary Club.
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The Municipal Hospital serves the town and surrounding villages. It is mainly a trauma centre with some elective work (Fig. 1). The Orthopaedic Department is run by a father and son team, the Drs Urovsky, flanked by half a dozen very inexperienced junior surgeons. The local needs are immense. For a start, no structured training exists. There is no formal teaching. They do not have PowerPoint or audiovisual facilities. The only meetings occur at 8.30am, under the vigilant chairmanship of a general surgeon who is the director of surgical services, and the orthopaedic team answer to him. The meeting lasts only 30 minutes and consists of reports of admissions from the night before. Specialisation is neither catered for nor encouraged, even though there are many lower limb trauma cases, particularly fractures of the ankle and os calcis. There was obvious scope for help here with organisation, planning, structured training and teaching. There is no out-patients department, only an office where the walking wounded queued, holding their x-ray films that had just been developed (Fig. 2). We introduced a basic feedback e-mail system whereby cases discussed and operated on during our visit were re-assessed. If a case was too complex to be operated on site, the Rotary and private funds were used to fly the patient to the UK where surgery was performed in Whitehaven. The first such operation was done recently on a young woman for an iatrogenic pes calcaneo-cavo-varus. Numbers vary, but for a typical ten days to two weeks visit I would see 60 outpatients with various problems, mainly acute, late-presenting or neglected trauma. Between 12 and 18 operations were carried out each week (Figs 3 to 5) mostly for the lower limb, two-thirds of which were of the foot and ankle. For some strange reason, complex os calcis fractures are quite common, even the bilateral ones. Other cases of interest were: congenital vertical talus, neglected talar and calcaneal fractures, Morton’s neuroma, hallux valgus, pes cavus, deficiencies of the tendon of tibialis posterior, diabetic feet, plantar Dupuytren’s contracture and accessory ossicles of the foot. A typical day starts with a ward round following the 8.30am meeting: these constitute the only structured and reproducible activities, after which the day’s events are completely haphazard, with patients knocking on the office door to be seen by the specialists. The operating theatres work flat-out from mid-morning to 6.00pm, with no lunch break. I survived on bananas and biscuits from my briefcase. Most evenings were spent wining and dining, or I should say vodka and dining, and sampling the local foods. The future needs of the Uzhgorod unit will depend on the political situation in the Ukraine. The country is split ideologically, with the NorthEast having an affinity for Russia and the West leaning towards Europe. As far as recent events in the Ukraine are concerned, I think that even if (or when) Ukraine is accepted by Europe, there will be a delay of at least ten years before Uzhgurod will be able to dispense with our help. A uthor
Fig. 3 Magdi Greiss (foreground) and Dr Olksandr Urovsky Sr. (Head of Depar tment), sor ting out implants pre-operatively
Fig. 4 Post-operative radiograph of a calcaneal fracture
details
Magdi Greiss
Cumbrian Clinic, North Cumbria University Hospitals caroleg1@supanet.com
Fig. 5 Bandaging af ter a tibial nailing
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BJJ News | I ssue 3 | J une 2014
Bridging the gap
Establishing a Link Between Addenbrooke’s Hospital, Cambridge and Yangon General Hospital, Myanmar he Republic of Myanmar (formerly Burma) is a nation of 60 million people located in South East Asia b et we e n I n d i a , C h i n a a n d Thailand. Its largest city and former capital, Yangon (previously Rangoon) is a city of six million inhabitants sprawling across the southern lowland plains. Until 2010, a system of military rule and suppression of civil and political opposition led to virtual isolation of the country with little international clinical or research collaboration. In 2008, cyclone Nargis devastated the coastal areas of Myanmar, killing over 120 000 people and exposing the lack of basic trauma care. At the time, not only was the spending by the government on healthcare considered the lowest of any country in the world, but the amount of foreign aid to Myanmar was the lowest per capita of anywhere apart from India. This led Myanmar to be ranked last of 190 nations in the World Health Organisation’s index of healthcare provision (Fig. 1). Free elections in 2010 allowed democratically elected officials to enter parliament for the first time in 50 years, which eased the restrictions on free travel
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Fig. 1 Local taxi in a poor countr y
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within Myanmar and renewed the government focus on the advancement of social welfare and healthcare. As a former colonial territory of the British Empire, the Burmese health care system has been built around the British model. The Yangon General Hospital (YGH) is a 1500-bedded unit which opened in 1899 and caters for all emergency and trauma work. With a catchment radius approaching 250 miles, it serves approximately 20 million inhabitants and conducts four thousand trauma operations per year. The Yangon Orthopaedic Hospital (YOH) is a former sanatorium, comprising two wards and three operating theatres where all non-urgent procedures are undertaken. Yangon also houses a paediatric hospital, a specialist orthopaedic-HIV unit and an inpatient rehabilitation centre where they manufacture their own orthoses. The lack of basic medical provision has encouraged the government to quadruple the annual spending on health from one to four dollars per inhabitant over the past 12 months. The emergency ‘192’ telephone number which lapsed around 15 years ago is
D. J. W. Cash A. R. Norrish V. Khanduja
being re-established and the previously nonexistent ambulance service is being phased in, with 70 ambulances staffed by trained paramedics due to serve the population of Yangon from next year. Against the background of improved healthcare funding and a government focus on nationwide trauma provision, we explored the opportunity of visiting Yangon with the aim of offering medical education and practical training to the Burmese healthcare professionals and to enable a research link to be established between Cambridge and Yangon for the mutual benefit of surgeons at both institutions. The original ‘needs assessment’ trips involved two oneweek visits to Myanmar to gauge the state of the government funded health service and to identify any particular areas of medical provision which may be enhanced. The outline proposal was drafted and submitted to the Tropical Health and Education Trust (THET), a registered charity which aims to support the development of health services in the world’s poorest countries. The proposal was deemed suitable by the charity and an original grant of £5000 was provided. This enabled
Fig. 2 Vikas Khanduja, Dave Cash, Alan Norrish (lef t to right) at the Shwedagon Pagoda in Burma.
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The lack of basic medical provision has encouraged the government to quadruple the annual spending on health from one to four dollars per inhabitant over the past 12 months.
Fig. 3 Ponseti Clinic at Yangon
funding for both visits to Myanmar, firstly a preliminary trip, which occurred in February by members of the pathology department to provide the hardware and technical training required for arterial blood gas analysis. The success of this trip laid the groundwork for the subsequent visit by members of the Cambridge orthopaedic department, which occurred over a seven-day period during June and July 2013. The project was registered with Addenbrooke’s Abroad, a non-profit-making organisation which aims to promote links between foreign healthcare institutions and Addenbrooke’s Hospital in Cambridge. By demonstrating to the charity the potential benefits of a link with Yangon, further financial assistance was provided for the booking of flights and insurance cover. Once in Myanmar (Fig. 2), we were warmly welcomed by the consultant body and able to assess their healthcare provision first-hand. The orthopaedic outpatient department, although basic, was able to cope with the influx of 150 patients per day. A previous visit by an Australian contingent had set up and provided training for a clinic specialising in the Ponseti technique for talipes equinovarus. Although no money had changed hands, the training and plaster equipment had been provided free of charge with stock replenishment handled from Australia. As part of the agreement, the
clinic was required to collect data on shortterm outcomes to identify any further need for training. This provision of equipment and subsequent auditing was a model which worked well for the provision of international assistance and we encountered it frequently during our visit. In this case it provided low-cost, low technology treatment for the 35 patients with CTEV who attended the clinic each week (Fig. 3). The operating theatres in YOH were well equipped by developing world standards. Surgeons had access to traction tables, suction and diathermy: four small fragment and four large fragment sets were available. A previous visit by French surgeons had developed a spinal surgery programme and contracts with Indian and Chinese manufacturers provided a supply of locked and non-locked plates, screws and K-wires. The hospital had embraced the SIGN nail programme where, by implanting the nail and forwarding the outcomes and post-operative X-rays to Washington, the SIGN intramedullary nail was provided and replenished free of charge for use with tibial and femoral fractures. Hip and knee replacement prostheses are sourced from Korea and whereas the government funds the operation, the patients must purchase the $3000 prosthesis themselves. It became apparent during our stay that the maintenance of equipment had been a huge problem over the previous 20 years.
Intra-operative X-ray equipment and an arthroscopy stack had been purchased in the late 90’s without a local service contract. When the equipment inevitably failed early due to recurrent power surges in the hospital’s electricit y supply, the technology was abandoned with the cessation of all arthroscopic procedures and the loss of all intra-operative radiograph guidance. Renewed funding has led to the re-acquisition of a functioning C-arm and, although an arthroscopy stack has also recently been purchased, there are, at present, an insufficient number of trained doctors and nurses for it to be used. Due to the ready availability of orthopaedic equipment and the skill of the surgeons we encountered, the focus of the visit was moved away from the provision of implants and towards practical training and research. We conducted a full-day trauma symposium based on AO principles (Fig. 4), which attracted 70 trainee doctors from up to 500 miles away (an overnight 16-hour journey from Mandalay). The success of this course formed the basis of two further symposiums in Mandalay and in Yangon which we conducted on our second trip to Myanmar in February 2014. Concurrently, a diagnostic model-based arthroscopy workshop has been agreed in principle as has live operating in theatre. The former will be expanded to address therapeutic arthroscopy in the second year.
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BJJ News | I ssue 3 | J une 2014
Effort has also been made to encourage the re-integration of Myanmar into the research community. Whilst the Myanmar Orthopaedic Association collaborates nationally, attendance internationally has until recently been impossible due to travel restrictions. As part of the Burmese surgical training programme, a research dissertation is submitted for the award of MMedSci (Ortho). While many of these theses contain large population epidemiological and clinical research, none has been published in peer-reviewed journals. To encourage integration with the international research community, we have instigated joint research with the Burmese surgeons which contrasts the presentation and treatment of trauma between Myanmar and the UK. A number of practical innovations were also noticed within the department, including a negative-pressure wound pump ingeniously manufactured out of locally available equipment at a fraction of the manufacturer’s cost with significant potential benefits for other developing countries. The Yangon University Medical Schools 1 and 2 each have a student population of around 4000 with trainees graduating MB BS after five years in addition to a Master’s degree. The intake of 36 orthopaedic trainees each year undertake a two- to three-year programme during which many pass the MRCS (Ed) examination which is conducted in English in Singapore. There had also traditionally been a significant number of Burmese trainees studying towards the MCh(Orth) examination in Britain but this gradually lapsed due to international travel restrictions. Many Burmese surgeons and high-ranking government health officials have completed periods of orthopaedic training in the UK National Health Service. During the week, we were fortunate to be granted an audience with the Myanmar Minister for Health at his ministerial office in the capital city Nay Pyi Taw (Fig. 5) and the Rector of the University of Yangon. During these meetings we were able to discuss and agree in principle a trainee link between Yangon and Cambridge. The link would allow Yangon trainees to visit Britain on one of two programmes. The first would be for those lacking GMC registration who would undertake a one-year clinical observership full-time MCh(Orth) qualification. The second, for those registered with the GMC, would be a two-year part time MCh involving a clinical fellow job on the orthopaedic wards and attracting the appropriate salary. The other aspect of the exchange would involve a continuous four- to six-month placement at YOH for a peri-FRCS East of England trainee. It was evident during our stay that, while operative techniques were similar between the countries, the pathology was markedly different. Much of the Yangon workload involves infection requiring basic limb reconstruction or amputation, and neglected trauma with its associated complications. It is certain that the experience gained during the placement will prove invaluable to the trainee in disease that is not commonly encountered in the developed world. After this visit, further fundraising events have taken place with the aim of funding an additional six trips to Myanmar over the next three years. The aim is to expand the number of consultants from Addenbrooke’s involved in the scheme and to further enhance both teaching and training of the Burmese surgeons and to strengthen the research and educational links between our hospitals.
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Fig. 4 Alan Norrish lecturing on Basics of Fracture Fixation at the Trauma Symposium in Yangon General Hospital.
Fig. 5 Vikas Khanduja, Alan Norrish, Thinn Hlaing and Dave Cash (L to R) at the Ministr y of Health in the new capital city, Nay P yi Taw. A uthor
details
D. J. W. Cash A. R. Norrish V. Khanduja Addenbrooke’s Hospital, Cambridge vk279@cam.ac.uk
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Notes from the road
Fellowship Report: Holland Orthopaedic and Arthritic Centre, Toronto, Canada
H. Kazi
Hussain Kazi reports on his Fellowship at the Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Canada July 2012 – June 2013
Fig. 1 Holland Or thopaedic & Ar thritic Centre
t was a hot June day when we left Merseyside and flew direct to Toronto. As a family we had been looking forward to the new experiences offered by a life in Canada for a year, but both my wife Victoria and I had a degree of trepidation as to how we would cope with Annabelle (three years) and Isaac (nine months) in a new city without easy access to friends or family. We arrived in Toronto early in the evening and after a trial of three taxis (we had 250 kg of luggage plus a pushchair, car seats and skis), arrived in our temporary apartment for the first week until our house became vacant. The first week consisted of getting to know the city and making sure my registration was sorted to start work after the Canada Day weekend (1st July). We found the weather a regular stifling 27°c and the absence of a car made things even more difficult with the children.
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At any one time, The University of Toronto (UofT) has 1000 fellows whose employment arrangements are mutually beneficial. The Canadian Taxpayer gets cheaper doctors who are usually very experienced and nearing the end of their training, most with salaries in the region of 50 000 CAD and the trainee gets high-volume experience at some world-class institutions. Toronto is the fourth largest city in North America and the capital of Ontario. Winters are moderate to cold and spring and summer glorious with consistently warm sunny weather. The city has a population of 2.7 million and is the most ethnically diverse on earth. Patients regularly come to clinic with a family member to interpret: many have lived in Canada for 40 years without learning any English. The official languages are French and English in equal measure, except in Quebec. No translators are provided by the hospital; this is the responsibility of the individual.
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BJJ News | I ssue 3 | J une 2014
Fig. 2 Fellows and Staff Surgeons (author is back right)
My fellowship was at the Holland Orthopaedic and Arthritic Centre (Fig. 1), which was a stand-alone orthopaedic hospital until it became part of Sunnybrook Health Sciences Centre. Sunnybrook is Canada’s biggest trauma centre and although moderate in size (1000+ beds) punches well above its weight internationally. The Holland Centre is Canada’s biggest arthroplasty unit and undertakes 2500+ joint replacements annually. My supervisors were Dr J. C. Cameron (knee), Dr J. Gollish (hip and knee), Dr J. J. Murnaghan (hip and knee), Dr C. S. Wright (Hip, knee and hand) and Dr V. M. R. Wadey (hip and knee, Fig. 2) Each consultant had their own specialist interest. Induction consisted of a two-hour session covering all the ins and outs of the hospital, as opposed to my usual NHS three-plus days. No clinical time was ever cancelled for meetings, audit, or ‘rounds’. These usually take place at 7.00 am or earlier so that elective lists or outpatient clinics can start promptly at 7.45 am. In our first induction meeting we learnt that instead of the usual four fellows there would be only two of us (one overseas fellow and one Canadian fellow did not arrive). This increased our workload and clinical experience significantly. For the first six months, until the arrival of an Irish colleague, we spent four days in theatre and one in clinic each week. It took a few weeks to adapt to a much earlier start at 6.00am. The first tasks included pre-operative clerking and surgical ‘orders’ for the day’s operative cases followed by a ward round, any rounds (meetings for education, pre-op planning or M&M) with a theatre knifeto-skin start time of 7.45 am. The organisation of most Canadian theatre complexes is different to those in UK. Instead of anaesthetic rooms there is a ‘block area’ of four beds supervised by a consultant anaesthetist with residents and fellows who will each be allocated cases. This ensures a high volume of experience and a very low failure rate. This not only speeds up the turnover Induction consisted of each room but also means of a two hour session that each surgical day runs smoothly to time. Most patients covering all the ins and have a spinal anaesthetic and outs of the hospital, as those for knee replacement an opposed to my usual additional continuous femoral NHS three-plus days. nerve catheter, from which they
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are weaned 48 hours post-operatively when they have regularly gained at least 110° of flexion. The operating rooms have no laminar flow but are serviced by a cleaning team between cases. Despite this and the absence of impervious gowns, the infection rate is < 1%. The rooms are very uncluttered and have fewer nurses than at home; usually two until 10.00 am with further circulating help after the first case. They are usually dual-trained and therefore will assist the anaesthetist if, rarely, a general anaesthetic is required, while also helping to run the surgical side of the room. Respiratory technologists are trained personnel who can supervise an anaesthetised patient while the anaesthetist is giving another anaesthetic in the block area or supervising another room, and they are used liberally. A doctor’s income in Ontario is through ‘billing’, with very few salaried doctors. It is, therefore, in the interest of both surgeons and anaesthetists to get through as much as possible in the working day, sometimes by using two rooms. Inpatient care is assisted by an internist (internal medicine consultant) who deals with any post-operative medical problems. High risk patients are cared for out of hours in the special care unit (similar to HDU), looked after by ourselves. The anaesthetists have a daily pain round where all patients are reviewed and treatment adjusted as needed. The Canadian healthcare system is similar to the NHS, whereby most care is free at the point of service (to the envy of their US neighbours). However, there are subtle differences in that any outpatient drugs are funded by the individual (as is dental, optical, cosmetic and bariatric surgery). This means that most people have an annual drug plan funded by an insurer, which may also cover the costs of a private or semiprivate room as an inpatient. My impression of this was that while drugs are far more expensive than in the UK, the system makes people individually responsible for their own health. EXPERIENCE
Elective My fellowship provided me with broad experience in hip and knee replacement. All consultants operate on both joints but one (Dr J. C. Cameron) also has a quaternary interest in knee malalignment, rotational problems and soft-tissue reconstruction. My knowledge of correction of patellofemoral alignment in total knee replacement improved infinitely as a result and I now consider factors and examination findings that I had not experienced in my registrar training. Patella resurfacing is almost universally taboo and the incidence of anterior knee pain after knee replacement is miniscule. During my year I carried out 220 TKRs and was
Fig. 3 Ar throscopic view of a medial meniscal allograf t in situ for 10 years (Photo Cour tesy of Dr JC Cameron)
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involved in almost 300, as well as 100 total hip replacements and a range of revision hip and knee replacements. I gained experience in osteotomies for unicompartmental arthritis, rotational problems and patella dislocation. I was able to learn the procedure of the MacIntosh LSOT iliotibial band ACL reconstruction and meniscal allograft transplantation, of which Dr Cameron has the world’s largest series Fig. 3) In the assessment of patients for surgery, the initial examination, scoring and metrics such as the six-minute walk test are performed by advanced practice physiotherapists (APP) who are educated to Master’s level and have spent a year under the tutelage of the senior consultants. This gives them great insight into thorough clinical examination, preferences and triaging of patients to the correct consultant. The APPs will use their clinical judgement and an algorithm to determine if they feel the patient is a good candidate in terms of need, potential outcome and compliance. If there is any doubt they can ask a consultant for review that day Trauma
Fig. 4 Kazi family bike tour of Chicago during the A AOS conference
I participated in the trauma rota at Sunnybrook at weekends. This provided broad experience and insight into the logistics of a major trauma centre (Sunnybrook is Canada’s biggest) and triage of the polytrauma patient. Education We planned all of our cases for the following week and presented these at the Thursday morning planning rounds, which also formed the basis of a research project. We were expected to present at Divisional Rounds at least once a month and over the year we covered lower limb arthroplasty comprehensively. Research My year afforded me a number of research opportunities including: • Meniscal allograft with and without osteotomy: a 15-year follow-up study. Status: Accepted for presentation at AAOS 2014 (Fig. 3) • Single-stage single component revision in infected hip arthroplasty Status: Final write-up prior to journal submission. • The presence of a learning curve in pre-operative arthroplasty templating. Status: Submitted to Canadian Arthroplasty Society 2013. Accepted for presentation at the Canadian Council of Medical Education Meeting 2014. • Lower Extremity Arthroplasty Fellowship Education in Canada: A Needs Assessment of Competencies. Status: Submitted to Canadian Arthroplasty Society, 2013.
Fig. 5 Family trip to Niagara Falls We were invited to all Orthopaedic Division social events as a matter of course. I gained immeasurable clinical and life experience. As a family it was a great adventure; we immersed ourselves in Canadian culture, made lifelong friends and enjoyed family weekends away. Financially, we will be crippled for the foreseeable future, but have no regrets! Awards
Financial and Social The year was a considerable financial strain. The salary is meagre, especially by Canadian standards and doesn’t even cover rent for a small family home. On-calls paid extra so I would try to work two week nights each week and two weekends a month but still needed to import significant amounts of money from the UK on an almost monthly basis. The extra call had a frustrating effect on home life but gave us spare cash to visit sights in and around Ontario including: Niagara escarpment (Fig. 5), Prince Edward County, Algonquin National park, Tremblant (Quebec), Ottawa and Montreal. We were lucky to receive help and assistance from both sets of parents: a ski trip with my parents to Blue Mountain over new-year was memorable for my daughter’s first ski lesson. My parents-in-law helped us to escape the cold with a trip to Jamaica in January. My consultants were all very hospitable and invited us to their weekend cottages, as well as arranging social events such as tickets to baseball and basketball games.
I was nominated for the University of Toronto, Department of Surgery Zane Cohen Fellow of the Year Award. Bursaries I am indebted to the following organisations for their generous financial support without which my overseas fellowship would not have been possible: • RCS / Ethicon Foundation Travel Fund • BOA / Zimmer Travelling Bursary • Charnley – Latta Travelling Fellowship A uthor
details
Hussain Kazi Hip Fellow, Exeter Hip Unit, Exeter, UK hussainkazi@nhs.net
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Notes from the road
Evaluation, solutions and innovation in complex hip replacements
E. Smith
Report on the 2013 Bristol Hip Arthroplasty Course he 10th Bristol Hip Arthroplasty Course (BHAC) took place in November 2013 with a faculty of 26 internationally recognised orthopaedic surgeons who debated the topic ‘Evaluation, Solutions and Innovation in Complex Hip Replacements’. The BHAC aspires to debate the challenges of outcomes, bearing surfaces and future design in primary and revision hip replacement. The style of the meeting throughout encourages everyone to contribute through discussion, debate and challenging the speakers. The topics covered included quality assurance, patient outcomes, joint preservation, primary total hip replacement (THR), bearings and new technologies, including how to deal with the problems of metal-onmetal bearings, strategies for the infected hip and revision hip replacement. The opening session was dedicated to ‘Quality Assurance’. The significance of the National Joint Registry for England, Wales and Northern Ireland (NJR) as a central register was evident. It is capable of identifying a wide range of factors that affect the outcome of joint replacement. A recent publication of NJR data identified a reduction in 90-day mortality between 2003 and 2011 after THR for osteoarthritis (OA). Four clinical management strategies, the posterior approach, mechanical and chemical prophylaxis and spinal anaesthesia could further reduce mortality. The influence of BMI also significantly affects outcomes. Patients with a BMI > 35 Kg/m2 have a greater risk of death. A high BMI is also a predictor for THR at a younger age and, in the morbidly obese, there is increased risk of infection, malposition of the acetabular component, dislocation and increased length of hospital stay. There was concern about the NJR’s recent initiative which aims to identify surgeons with higher than expected poor outcomes (‘outliers’), as ‘standardisation’ of the evaluation criteria fails to engage the full complexity and case mix of the operations performed.
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The economic aspects of provision for hip replacement identified a conundrum set to test providers in the coming decades. There is an increasing and ageing world population with an epidemic of obesity in affluent countries, where diagnostic and treatment technologies constantly advance. The need to contain rising costs while increasing funds therefore presents a fundamental problem. The evaluation of Quality Adjusted Life Years suggests that patients are denied the benefits of an active and healthy life when operations for OA of the hip are delayed and ‘rationing’ of healthcare is thought to be a real possibility as the balance of power shifts from healthcare professionals to those who pay. Following the failure of the UK’s regulatory sur veillance system to identify the high failure rate of metal-on-metal (MoM) bearing prostheses, the newly established Beyond Compliance system (Beyond the compliance of the CE Mark), aims to subject new implants to far greater scrutiny. The level of risk will be evaluated more fully by gaining a greater understanding of the product and advising on the rate of release to market. A pilot study is underway. Joint preservation is the cornerstone of hip replacement surgery and this is most important in young patients (< 50 years) who need a hip replacement, as they now account for 4% of all THRs performed in the UK. The vogue in THR in this group ten years ago was large-head MoM implant. This bearing surface proved to be a poor choice and follow-up of this group of patients is critical. The challenge remains to provide an implant which has a reasonable chance of surviving beyond 20 years. Based on the findings of pericetabular osteotomy presented at the meeting, certain conditions appear to predispose to early arthritis. No patient with untreated dysplasia and a centre-edge angle of less than 16° reaches age 65 with a well-functioning hip. Progression of OA is related to the failure of the chondrolabral junction which is associated with recurrent
subluxation. A symptomatic hip can be treated by periacetabular osteotomy to recreate the correct orientation. Another study showed that not all patients with a dysplastic hip develop secondary OA. A good outcome is therefore possible even in the presence of adverse radiological features. The Keynote lecture by Henrik Malchau discussed the problems and challenges of THR in the health systems of the United States and Europe. Public reporting of patient outcomes was felt to be the single most important step affecting accountability for healthcare systems. The pitfalls of early adoption of new implant technology were discussed and, in accord with Beyond Compliance, it was thought that incremental rather than chaotic introduction of new technologies was more likely to affect improved outcomes. While doctors are obliged to treat patients on evidence-based principles, patients should be protected from all hazards associated with hip surgery. Many governments now pay doctors on the basis of evidence and President Obama’s healthcare plan adopts this principle. The USA therefore has the potential to make savings if a central registry is introduced. This would facilitate unbiased evaluation from which political and/or industrial involvement would be removed. In primary THR, stem selection, cup position and gait analysis were debated. For patients with DDH, stem selection depends on bone shape and quality and limb deformity. The benefits of using a cementless implant with a modular distal loading ‘Wagner-like’ femoral component and an oblique subtrochanteric osteotomy were presented. Laboratory-performed gait analysis after THR and resurfacing arthroplasty (RA) showed a more natural gait with RA. However, the subtleties of the impact of different implants must be investigated in greater detail. In cup placement the difficulty of achieving accurate inclination and anteversion remains a problem. These are affected by the position of
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the patient on the table and identification of the true position of the individual acetabular socket. It was suggested that using the transverse acetabular ligament as a marker to position the cup was effective. Cup orientation in DDH is a far greater technical challenge and guidance was offered to identify the position of the natural socket so that the surgeon can place the cup accurately. A European centre of excellence provided evidence for a high survival rate with the use of a cemented THR in young patients. Outstanding outcomes in acetabular reconstruction using impaction grafting, support cages and screws had been achieved. Lessons learned from the experience of more than 4600 Corail cementless femoral components were presented. Problems were shown to occur in patients with a narrow femoral canal and thin cortices. Excellent results were presented with the use of a collar, especially with hard-on-hard bearings. Pre-operative templating is critical and the avoidance of smaller stems in male patients was recommended. Intraoperative fractures should be identified and treated immediately. Problems with the survival of MoM bearings have been a prominent feature of previous BHAC meetings. After an avalanche of recent activity on the subject this was an item of great interest at the 2013 course. The first presentation in this session considered revision of mixed MoM arthroplasty. All the pitfalls of using different metals at the head/trunnion junction were identified with an emphasis on problems of trunnion corrosion. The timing of revision hip surgery and patient factors resulted in a range of outcomes: it was noted that the failure of resurfacing arthroplasty was not as aggressive as that of large-head MoM implants. In a discussion on trunnionosis, the taper design (length, diameter, surface and finish), impaction technique and the use of large heads affecting.torque and increasing the horizontal lever arm were emphasised In the grading of adverse reaction to metal debris (ARMD) it was clearly shown that metal artefact reduction sequence and not ultrasound is the ultimate diagnostic tool for ARMD. Provided the scan is of high quality it can also exclude infection. Pseudotumours have become an accepted norm in ARMD and the spectrum of their pathogenesis was discussed. It was demonstrated that specific histological features
are associated with high wear and numerous publications have shown that surveillance and early revision are the bedrock of treatment. Discussion on the ‘class’ effect of MoM bearing surfaces highlighted the difference between resurfacing arthroplasty and largehead MoM hip replacement. The design of the taper is the factor thought to affect the difference between these designs. A Kaplan-Meier survival curve was shown which offered a valuable illustration of the hard end-points of revision and death. Using this measure, the BHR shows 100% survival at 14 years in men with OA < 50 years. A discussion of the problems associated with MoM bearings emphasised the problems of safety with this bearing surface. Patients undergoing cemented THR showed a statistically significant increase in mortality, as reported in a retrospective analysis of NJR data published in the BMJ in November 2013. The rationale for the use of large head ceramic-on-ceramic bearings was debated after the presentation of a mid-term study undertaken at various centres and had shown good results. Strategies for the infected hip compared the one- and two-stage exchange. The key to the one-stage approach to acute infection was thought to be early debridement and exchange of all mobile parts. Debridement, antibiotic and implant retention had a very variable success rate (14% to 100%). The management of revision hip replacement was debated in the final session of the meeting. A case was made for the use of ceramic-onceramic bearings in young active patients. It is essential to insert the ceramic liner accurately to prevent fracture. When this occurs, aggressive soft-tissue debridement and lavage are critical to the success of the revision surgery. If small fragments cannot be removed, a polyethylene liner with a ceramic head should be used. It was felt that a ceramic head should be inserted on a fresh taper due to the risk of existing damage to the trunnion. The long-term success of impaction bone grafting of the acetabulum was shown by its originators to have a 72% survival rate. It was noted that where bone defects had been severe, specific problems had occurred. T h e ‘ Pa p r o s k y C l a s s i f i c a t i o n ’ w a s presented as a basis for discussion of massive proximal femoral bone loss. Proximal femoral replacements have recently improved in design such that soft tissues can be reattached and
For more information on the Bristol Hip Arthroplasty Course visit www.bristolhip.com stemmed fixation used. Significant defects require drastic solutions, but the new generation of implants offer surgeons several options and improved fixation. The indications and method of bulk strut grafting for revision of the femur were discussed. It is thought that the use of a strut graft is dependent on its size and fixation and remains an important part of the armamentarium of the revision arthroplasty surgeon. Modular femoral components can bridge the gap between relatively simple problems and the more complex situations when revising the femur. Numerous factors must be considered when deciding on the technique of revision, but the most important are bone loss, surgical experience and philosophy. Improved fixation, leg length and component stability have been achieved with advanced designs of porouscoated stems: 80% of cases were shown to be successful with a cylindrical porous-coated stem. Stability of the implant is an important factor in obtaining satisfactory results. The disadvantages of modular stems were presented and a specific study with the REDAPT stem showed excellent short-term results though it was noted that larger scale studies were needed. The case for augments rather than trabecular metal was discussed in relation to the more historical cup-cage designs. Extremely severe and complex cases with extensive bone loss were presented. The literature was reviewed and it was found that with trabecular metal, such implants provided options to address most acetabular defects. Only revision and tumour surgeons who regularly undertake this type of surgery should operate on these severe cases.
A uthor
details
Evert Smith Consultant in Trauma and
Orthopaedic Surgery and Honorary Clinical Senior Lecturer, University of Bristol
evertjsmith@hotmail.com
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Orthopaedic history
A brief history of orthopaedic surgery in New Zealand rthopaedic surgery as a specialty was not formally practised in New Zealand before 1918. Its inception was the result of a request from the New Zealand Government for six New Zealand surgeons to be trained under Robert Jones, in the United Kingdom. He was one of the few surgeons interested in the treatment of fractures and brace manufacture while most orthopaedic surgery at the time was carried out by general surgeons and aimed at correcting deformity in children. Jones’ reputation and work in fracture management, first as SurgeonGeneral for the Manchester Ship Canal, then Inspector of Military Orthopaedic Hospitals during the First World War, led to this request. Hence Gower, Mill, Ulrich, Wallis, White and Wylie became New Zealand’s first true orthopaedic surgeons. Since then the development of orthopaedic surgery as a specialty in New Zealand has been effected by the drive and enthusiasm of a number of individuals. The Great War and its aftermath enabled the development of orthopaedic surgery as a civilian specialty. After the Second World War a number of young New Zealand doctors who had trained in London, Oswestry and Liverpool returned to New Zealand to work in both public hospitals and private practice. These were part of an international community who were keen to stay in contact and to share their knowledge and skills to enhance the practice of orthopaedic surgery. From this gestational period emerged the New Zealand Orthopaedic Association. It was established on 17 February 1950 when seven men, Blunden, Cunningham, Elliott, Fitzgerald, Gillies, Jennings and Lennane met in Wellington. A motion was passed that the New Zealand Orthopaedic Association (NZOA) should be an independent organisation with a Constitution based on that of the British Orthopaedic Association. An Annual Scientific
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Meeting (ASM) was an essential aspect of the Association. The first was held at Christchurch Hospital in September 1950 (Fig.1) and the practice continues to this day (Figs 2 and 3). The orthopaedic fraternity in New Zealand has been characterised by strong determined
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men, nowhere more so than in the Presidents of the Association. While every President has contributed to its evolution, there are some whose leadership had a particular style which has helped to characterise the orthopaedic surgeon in the eyes of the wider medical community in New Zealand. For international readers, New Zealand has a marvellous public health system provided by the public purse through taxation. Orthopaedic surgeons have ready access to the Minister of Health and associated bureaucracies to lobby for the increased allocation of resources. Once a qualified orthopaedic surgeon is vocationally registered with the New Zealand Medical Council they can set up in private practice and/ or take up a consultant’s position in the public hospital service. The Accident Compensation Commission (ACC), established through legislation to provide comprehensive, nofault personal injury cover for all New Zealand residents and visitors has been of great benefit both to patients and to surgeons. As many injuries need to be treated by orthopaedic surgeons this scheme has generated a third element to their practice. The opportunities for research and innovation are high especially
Fig. 1 First NZOA ASM 1950
F. Gilkison
as most orthopaedic surgeons have a mixed practice in which patients are seen either in the public hospital system, through private practice as privately-funded patients or through both as ACC-funded patients. Alexander Gillies, the first President of the Association, started his career in a “Jones hospital” with further appointments in the Mayo Clinic in the US and the Lockwood Clinic in Canada. This desire for international training and learning from the best remains a strong attribute of New Zealand Orthopaedic Fellows. Gillies remains the only orthopaedic surgeon to have been knighted although others, including most recently Allan Panting (MNZM), have been recognised by the Queen for their services to surgery. Gillies was presented with the NZOA Presidential Jewel of Office by the Queen Mother in 1952 and since then it has been worn by every President (Fig. 4). J. Kennedy Elliott, a founding member of the Association, was the first secretary and later the sixth President (1960 and 1961). He was awarded the OBE for his war service where he developed an interest in amputees and their rehabilitation. On his return to New Zealand he produced a report which had considerable influence on the establishment of the amputee centres in New Zealand. He also developed a keen interest in paediatric orthopaedics dealing particularly with congenital deformities.
Fig. 2 NZOA ASM Dunedin 1963
Fig. 3 NZOA ASM Dunedin 2012
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Alan Joseph Aldred, the tenth President of the Association (1968 and 1969), was awarded a CBE in 1982. He had a long association with the Royal Australasian College of Surgeons including being an examiner and serving a term on the Dominion committee. The main thrust of his presidency was to develop academic orthopaedic surgery separate from the umbrella of general surgery and to encourage orthopaedic education. Oliver Ross Nicholson (Obituary BJJ News Issue 2), the 17th President of the Association in 1982, was awarded an OBE that year. He probably contributed as much as any other person to the advancement of the specialty both in New Zealand and internationally and was the only New Zealander to have been elected as a corresponding member of the American Orthopaedic Association. He played a pivotal role in the development of the spinal unit in Auckland and the founding of the academic unit in the department of surgery at the University of Auckland. He was committed to training and will be remembered for his passion and perhaps at times acerbic temperament by many current New Zealand orthopaedic surgeons. Colin Hooker was the Association President 1984 to 1985. His extremely worthy contribution to the Association is through his authorship of the book Orthopaedics in New Zealand – a history of the first 90 years of orthopaedic surgery in New Zealand which was published in 1996. Geoffrey Lamb’s presidency was notable for his administrative skills and the recognition that the Association would benefit from the establishment of a physical secretariat in the capital, Wellington, and run by non-clinical staff to alleviate some of the pressure of office on the President and Executive committee. Victor Hadlow, the 20th President (1988 and 1989), deserves recognition for his unswerving
Fig. 4 NZOA Presidential Medal
devotion to improving the quality of patient care and minimising the influence of non-clinical bureaucrats and hospital managers. A political animal at heart, Victor took on the bureaucracy to develop clear guidelines for the management of orthopaedic surgery in hospitals. John Cullen’s (1992) innovations and desire to push the boundaries of contemporary orthopaedic management has seen him as the champion of the new public Elective Surgery Hospital in Auckland. Whereas some colleagues feel that the separation of acute from elective surgery is not beneficial to the management of a department, there is no doubt that the increase in activity possible in an elective-only unit has merit. With the huge predicted increases in demand for elective orthopaedic surgery from New Zealand’s ageing population, different ways of managing scarce resources need to be considered and John is at the forefront of this. No history of New Zealand Orthopaedics would be complete without reference to the strategic work of Professor Alastair Rothwell, President from 1995 to 1996. His Presidency saw the birth of the New Zealand Joint Registry. Now in its 14th year it is recognised internationally as a unique data resource for the practice of joint replacement in New Zealand. One of the main aspects that sets this registry apart from other international registries is in its data collection compliance which is 98% or better and includes the collection of patient derived outcome scores. Professor Rothwell established the registry and remains its hands-on supervisor. He managed to gain his colleagues’ confidence in the importance of the registry to the extent that they unanimously record all their primary and revision joint replacements both in private and public practice. This has given New Zealand a remarkable longitudinal resource, which is highly prized by Government departments, yet remains in the hands of the NZOA. Professor Geoffrey Horne (2002/2003), foreseeing the huge increases in demand for orthopaedic surgery, notably hip replacement, took his concerns to Government and after writing excellent research articles on the need for increased funding was able to convince the Minister of Health of the need for a substantial increase in public funds for orthopaedic surgery, referred to as the “hip initiative”. Many elderly New Zealanders previously unable to get a hip replacement have now been treated and can thank Professor Horne for his initiative. The Tregonning brothers Garnet (1999/2000) and Russell (2005/2006) were both Presidents and brought different approaches, the former
from the metropolis of Auckland and the latter from the political capital, Wellington. The NZOA continues to have a strong relationship with the Royal Australasian College of Surgeons. Richard Lander in his 2013 Presidency forged a principle-based partnership agreement with the College for ongoing Fellowship training and International Medical Graduate assessment. Orthopaedic surgery in New Zealand has been founded on a strong philosophy of fraternity. The Presidential Line established t h ro u g h t h e C o n s t i t ut i o n e n c o u ra g e s this by easing the huge demands on the President, especially with the travel and speaking commitments to the Carousel of Orthopaedic Associations. The Presidential Line is a four year process starting with a 2nd President Elect, President Elect, President and Immediate Past President. What of the future? Innovation and teaching to enhance the “art and science” of orthopaedic surgery in New Zealand, the Association’s main objective, is an ongoing commitment. Professor Gary Hooper’s research work and establishment of the NZOA Research Foundation is significant, as is Kevin Karpik’s 14-year commitment to registrar training through his involvement with the Education Committee and current position as a RACS examiner. The future of the association continues to look strong as young Fellows emerge on the scene and start to develop their international reputation. Matthew Boyle’s research presented at the 2014 AAOS was selected as one of the top 15 ‘game changers”. The Association, while starting in 1950 with 16 orthopaedic surgeons in New Zealand, has grown today to 235 Full Members; 44 Senior Members, many of whom are still active; 12 Associate Members; 76 Corresponding Members (most of whom are recent New Zealand Fellows on international fellowships, the traditional post-Fellowship pathway before accepting a consultant position) and 51 Trainees. A number of women are now gaining their Orthopaedic Fellowship and making their mark. They follow the pioneers such as Karen Smith, the first New Zealand woman orthopaedic surgeon. With the volume of orthopaedic surgery waiting in the wings as our population ages, the Association can only continue to develop and grow. A uthor
details
Flora Gilkison Chief Executive, New Zealand Orthopaedic Association admin@nzoa.org.nz
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Orthopod’s view
Experience of a Fracture Surgeon working in a District General Hospital fter working as a consultant orthopaedic surgeon in the Royal Air Force and 15 years at King’s Mill Hospital in Mansfield, I took up a post as a trauma Consultant at Queen’s Hospital, Romford. I believe that the lessons learned in this innovative post may be helpful for those planning to develop fracture services in a District General Hospital. The challenges to the provision of a comprehensive fracture service in the UK are increasing. Trainees are finishing their training having had less exposure to the management of fractures and Consultants are often on-call as infrequently as one in 12 which reduces their experience of patients with fractures. Increasing sub-specialisation means that fractures outside the consultant’s area of expertise can cause difficulties. Until a true 24-hour service exists, recruiting help from other colleagues will be difficult both within and especially out-of-hours. The situation at Barking, Havering and Redbridge NHS Trust before my appointment reflected some of these problems. The Trust is on two sites with two Accident and Emergency Departments separated by 4.5 miles. It is very busy and sees over 600 hip fractures annually. Elective orthopaedics is undertaken exclusively at the King George site with fractures managed at Queen’s. Before the establishment of the North East London and Essex Trauma Network there was a Regional Neurosurgical Unit at Queen’s. This was designated as a Special Trauma Unit, although now, after the re-organisation of the Network, the Queen’s site now functions as a Major Trauma Unit. It no longer takes the multiply-injured, who are diverted to Major Trauma Centres. Before the appointment of two trauma consultants the existing orthopaedic consultants covered the Queen’s site for a trauma week on a 1:12 rota. In order to address these problems the Trust appointed two consultants to undertake only trauma with no elective duties. Between them, they cover two nights on call during the week,
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J. Hambidge
John Hambidge reports on his new career in an innovative post
thereby reducing the on-call commitment of the other consultants to five days out of seven during their trauma week. The posts created extra contractual time for the elective consultants and were hence self-funded. The Trust runs 22 trauma lists each week. These are now consultant-led for ten sessions and associate specialist-led but consultant supervised for 12. The trauma consultants lead five sessions and supervise four; the trauma-week consultant leads five and supervises eight. We believe we have addressed some of the problems of the provision of cover for complex fractures which may be outside the scope of the trauma-week consultant’s sub-specialist interest. For example, a specialist upper limb trauma consultant can help when a complex proximal humeral fracture presents in a week when the trauma week’s consultant has a specialist interest in knee surgery and the other upper limb consultants have a full elective workload in another part of the Trust. The remaining issues are to do with out-of-hours and in particular, weekend cover. Open fractures not covered by British Orthopaedic Association Standards of Trauma (BOAST) still need to be addressed urgently. Fracture dislocations cannot always be safely observed and should not wait over a 48 hour weekend. Specialist referral patterns are in place for hand and pelvic injuries. On occasion, the on-call consultant may be asked to work outside his comfort zone. Also, the reduction in trauma operating runs the risk of further de-skilling the elective consultants who now lead five trauma lists every 84 days; that is 22 lists per year. At a recent audit we identified 20 tibial plateau fractures which had been managed operatively in the course of a year. The trauma consultants operated on ten of them leaving the remaining cases to the elective consultants, so that each of them operated on less than one per year. Some of the consultants feel that they are able to provide a full range of fracture management while others prefer to hand over
complex cases to the trauma consultants, whose role therefore varies on a weekly basis and calls for a degree of tact and flexibility. A daily trauma meeting takes place followed by a ward round. The trauma consultants attend all of the trauma meetings in the working week accompanied by the traumaweek consultant. There is a handover meeting on Monday morning. Two areas of difficulty have been identified; ownership of patients and recording the decision-making process. Patients admitted through Accident and Emergency to the wards or the rolling day case list (called the virtual ward) go under the name of the on-call trauma consultant of the day or week. Patients admitted from a fracture clinic after a first visit are discussed with the on-call consultant and are then admitted under his name. Patients admitted from a fracture clinic under other circumstances remain under the name of the fracture clinic consultant. Consequently, a patient may be seen in clinic by one consultant, have his case discussed with a second who he has not seen and be admitted and operated on by a third who acts as technician, his case having been discussed and a consensus opinion taken at a trauma meeting when more that one consultant is present. This line of care is confusing to patients. The governance line is difficult, poorly documented and relies heavily on team working and a coherent department. Difficulties can arise when the opinion of the admitting or operating consultant differs from that of the consultant who initially saw the patient. Discussions in the trauma meeting are made without being able to see the patient. We are in the process of developing a system to record the discussions in the trauma meeting. Team-working and informing patients of the process have been identified as particular issues. I would view my post as that of a fracture surgeon rather than a trauma surgeon. There are a group of challenging fractures which occur relatively rarely. A consultant covering 1:12 may have exposure to these cases with a frequency
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which makes it difficult to develop or maintain skills. Developments in trauma as well as in all other branches of medicine occur rapidly. It appears to make sense for these cases to be seen by somebody with a subspecialist fracture interest. At present two obstacles prevent this from happening on a regular basis. Some consultants do not welcome the development of fracture surgeons and believe that they are trained to manage complex fractures as a result
of their specialist registrar training and are able to maintain those skills. Two fracture surgeons cannot provide a comprehensive cover within our Trust. In the long term I expect that surgical fracture management in the UK will become a separate specialty in its own right but that this will take some time. In the meantime we need to plan how we can cover an increasingly difficult situation. Currently, we have too few specialist fracture surgeons to provide complete
cover but as this group expands there will be decline in complex cases undertaken by orthopaedic surgeons often at levels too small to maintain skills. A uthor
details
John Hambidge Barking Havering and Redbridge NHS Trust, Queen’s Hospital, Romford, Essex johnhambidge@doctors.org.uk
Orthopod’s view
Sculpture and the female form o it from memory, make it private’. This was the advice I received in 2007 from Phyllida Barlow, Professor of Sculpture at the Slade School of Art, when I had the temerity to show her images of some of my sculptures of the female form. This plea for intimacy and a personal statement struck a chord. However, going public with private thoughts can be difficult. I have also received over the years good advice on artwork from John Olsen, contemporary Australian painter, who likes to challenge with, ‘OK, but what does it say?’. I studied medicine in Liverpool in the 1960’s when the Beatles had just given a buzz to Merseyside and Liverpool Football Club under Bill Shankly couldn’t stop winning. Shankly was a dour Scotsman who in an interview famously observed, ‘Some people believe football is a matter of life or death, I am very disappointed with that attitude. I can assure you it is much, much more important than that.’ I think the same about art. Whereas football is a team game watched by supporters, art is a lonely business mostly without financial guarantee and open to commentary by every Tom, Dick and Harry. Not quite the security and backup offered by a career in medicine. So why choose to be an artist? No doubt there are many reasons but on creativity William Blake, poet and painter, had this to say:
C. R. Weatherley
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‘I must Create a System, or be enslaved by another Man’s. I will not Reason and Compare: my business is to Create.’1 BACKGROUND
Man has been creating images of the female form for a very long time. One of the earliest
Fig. 1. Torso. a) Plaster maquette, H 12 inches. known is the Woman of Willendorf which dates to about 25,000 BC. Despite her ample proportions, she is only 11 cm in height and is variously regarded as showing a goddess, sex symbol or archetypal mother figure despite also being labelled as monstrous.2 The Greeks and Romans had clear concepts of physical beauty, and created sculpture along those lines. Similar classical values were revisited centuries later in the Renaissance in Christian Italy. 3 Whatever the religion, divine inspiration appears to have helped. In Ovid’s Metamorphoses, written around the time of the birth of Christ, there is a tale about a sculptor, Pygmalion.4 Wifeless and unable to find the perfect woman, he sculpts one who is then brought to life by the goddess,
b) sculpture (Bath stone) H 30 inches. Venus. Alas, Venus has gone and Jesus doesn’t do it but one can still dream. Virtuosity of technique in carving the human form probably reached its zenith with the sculpture of Bernini (1598–1680) in the Baroque period. In more recent times, the French sculptor Auguste Rodin (1840–1917) sculpted the human figure and took inspiration from the Italian masters and the ancient Greeks. He had a realistic albeit expressionistic style, which contrasted with the monumental simplicity and classical serenity of his compatriot and contemporary, Aristide Maillol (1861–1940). Little by little, sculpture moved away from the figurative representation of the human form, and one of those initiating this process
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BJJ News | I ssue 3 | J une 2014
was the Romanian sculptor, Constantin Brancusi (1876-1957).5 Brancusi had gone to Paris and been influenced by Rodin but chose not to work with him. Whereas modelling in Rodin’s hands, however intimate the subject matter, had become public, aggressive, extrovert and generalised, Brancusi realised carving as the opposite mode: private, individual, separate, concentrated and quiet, with material as the fundamental determinant of form. 6 Truth to material became a code of practice, if not a mantra. Last year the British sculptor, Anthony Caro, died at the age of 89. He trained as an engineer and in the 1950’s became an assistant to Henry Moore. Welded steel was his medium. In an interview he was asked if he was always in control. ‘I hope not’, he said, ‘it is a dialogue between me and the stuff’. SO WHERE AM I?
I retired from being a spinal surgeon about five years ago, since when I have pursued my interest in art and sculpture -- a switch from repair to creation – and in particular in the human figure. Whether a lifetime’s involvement in human anatomy will help to create sculpture in the 21st century is open to debate, but I take succour in the fact that Leonardo and other renaissance artists gave it some thought. With the background I have given, allow me now to discuss aspects of two of my figurative stone carvings and leave the reader to consider a workin-progress.
Fig. 2 . Torso. a) original block of stone. the technical expertise to do so. Gill believed that the inspiration came with carving direct and not the accurate reproduction in stone of a clay model.7 TORSO 2 (Figs 2a and 2b)
This is an example of direct carving. I left the top ledge of the original block and worked down. The final surface was created with stone files (rifflers) and different grades of wet and dry paper. WORK IN PROGRESS: THE KISS (FIG. 3)
TORSO 1 (Figs 1a and 1b)
The model posed in the extended position with her head back and arms in the air for limited periods of time over a number of weeks. I was interested in the counterpoise between the plane of the neck to the breasts and that running nearly at a tangent from above the waist to the buttocks. The sculpture was modelled in clay, after which a mould was made and the figure cast in plaster for further work. The plaster model (maquette, Fig. 1a) was then scaled up for the stone carving (Fig. 1b). It was a surprisingly accurate but tedious business. The use of clay or plaster models was in vogue from late mediaeval times until the end of the 19th century. Earlier sculpture had been created by direct carving - that is by the sculptor carving the figure straight from the block without recourse to a model in a different material. In Britain, Eric Gill (1882–1940) is credited with bringing the direct carving approach back into use, and his earlier training as a stone-mason and cutter of letters in stone and wood gave him
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‘The Kiss’ has long been a favourite subject for artists. Perhaps the best known sculpture of modern times on this theme is the massive, realistic and whole body ‘The Kiss’ by Rodin done in the early 1900’s. Less well-known and more abstract and personal are those done by Brancusi. Like Gill, Brancusi also used the direct carving technique, and his version of ‘The Kiss’ involved two half-length figures whose forms hardly violated the cubic mass of the stone from which they were carved. I see the subjects representing two masses abutting but with sensitivity about the area of contact. Gender is not important – it could be a male and female or same-sex kissing – the stone would not know. One might be dominant and the other subservient, which might give force and energy to a piece otherwise in equilibrium – but dominance and subservience would simply be a subjective assessment. Besides, kissing isn’t just mechanics. As e.e. cummings, the American poet, observed:
b) Por tland stone. H 21 inches ‘Since feeling is first who pays any attention to the syntax of things will never wholly kiss you’.8 To date, I have created a maquette using cardboard from a porridge oats box (recycling at its highest level). I believe it works, but whether it will transfer into stone, which is a different material, we will have to wait and see. Perhaps the impermanence of cardboard is more apposite to a kiss than something which would clearly see me out. POSTSCRIPT
This article should come with a government health warning. It is intuitive rather than logical and there are no evidence-based criteria about it. Talking about the act of creation Picasso said: ‘If you know exactly what you are going to do,
Fig. 3. The Kiss. Cardboard. H 9 inches W 11 inches.
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what is the point of doing it?’ Hardly a maxim to follow when doing surgery. To have the capacity to develop ideas remains essential not only in art but also in science. I understand that when NASA landed a man on the moon, one of the first phone calls was not to the rocket scientist or to the astrophysicist but to Arthur C. Clarke, science fiction writer, for having the vision which created the programme.
This essay is based on and extends a talk given to the Old Oswestrians Club on 14th June 2013 entitled ‘The Endless Quest for the Perfect Female Form’.
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and Hudson, 1977. 7. Collins J. Eric Gill: Sculpture. London: Lund Humphries, 1992. 8. Cummings EE. Selected Poems 1923 – 1958. London: Faber
1. Vaughan W. William Blake. London: Tate Publishing, 1999.
and Faber Ltd, 1960.
2. Cook J. Ice age art. London: The British Museum Press, 2013. 3. Burckhardt J. The civilization of the renaissance in Italy. Vienna: The Phaidon Press, 1965.
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Chris Weatherley
karen@1thequadrant.com
BJJ News : your views
The Glasgow Fracture Pathway; the right answer to the wrong question Jenkins et al1 outline a system of virtual fracture patient review (BJJ News, March 2014) which has become familiar to us in the West of Scotland, and has almost attained the status of Scottish Government health policy. The evidence from the Glasgow Royal is impressive, in that 26% of patients referred to orthopaedics were discharged without attending a fracture clinic. However, these cases still had to be reviewed in a virtual clinic after attending the Emergency Department (ED). I think that this system has addressed the wrong problem and that the complete lack of or thopaedic and fracture knowledge in the majority of EDs allows a system of ‘one way’ referral whereby no orthopaedic treatment or management is possible, or allowed, by ED staff. Also, the four-hour target does not permit orthopaedic staff the opportunity to see after referral , treat and discharge, or advise and refer back. A generation ago many Casualty departments were administered by orthopaedic surgeons and staffed by juniors who could, and were encouraged to, manage and discharge most minor fractures and injuries without review
6. Tucker W. The language of sculpture. London: Thames
REFERENCES
4. Hughes T. Tales from Ovid. London: Faber and Faber Ltd, 1997.
Letters
5. Cabanne P. Constantin Brancussi. Paris: Terrail, 2002.
The development of the speciality of Emergenc y Medicine has meant the appointment of many ED Consultants who have little or no training or experience in orthopaedics, and who are unable to train their juniors in the management of the conditions now overloading fracture clinics. EDs are now ver y busy acute medical facilities, unable and often unwilling to provide acute fracture or injury care, and discharge. The increasingly risk-averse nature of emergency medical practice is also a factor which does not help. I would ask, not how do we change the fracture clinic, but how do orthopaedic surgeons reclaim the front door, where the more senior or knowledgeable the opinion, the more likely a patient will be managed correctly and expeditiously. In the modern ED this is not presently the case for minor and intermediate orthopaedic injuries. The GRI may be the exception, but most EDs refer directly to the fracture clinic, irrespective of the nature of the condition. Medical Clinical Assessment Units (CAUs) are the perceived solution to the medical crisis in the ED, and provide a senior clinical opinion at the front door, optimising early
E - m a i l : bj j news @ bo ne andj o i nt. or g . u k care and preventing hospital admission. EDs will be bypassed and may thereafter become oases of calm. In my hospital the pilot deployment of a consultant or t hog er iatr ician to t he ED considerably reduced the number of acute elderly admissions, and subsequent clinic visits. The GRI ED staff has been engaged by a prolonged campaign by the GFP group, and now discharge m a ny p a t i e n t s w h o w o u l d previously have been referred to a fracture clinic, and they are to be praised for this. However not all ED units may be so accommodating. Perhaps the answer to the unasked question is to deploy experienced senior orthopaedic staff, in the ED as first responders. They would have the skills to manage and discharge many of the patients who would otherwise have to be reviewed at the virtual or other fracture clinics. This system of early acute orthopaedic input has had impressive effects in the early diagnosis and management of patients with hip fractures,and should be extended to all patients with fractures. Perhaps the day of the “take-all” fracture clinic is passing. With front door orthopaedic management,
patients who need specialist fracture care will be sent to the appropriate surgeon without delay. Those who require such fracture surgery would be listed for semi-elective surgery, and could wait at home rather than at present being admitted by inexperienced junior staff and subsequently simply queuing for their operation in a hospital bed. Furthermore, there is likely to be a huge transfer of funding from the secondary hospital service to the Communit y after the implementation of the Health and Social Care integration policy on both sides of the border. Many of the patients presently dealt with for follow-up treatment of minor injuries at fracture clinics will have to be managed by community services, which will have all the money.
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REFERENCES 1. P. J. Jenkins, A. Gilmour, O. Murray, et al. BJJ News Issue 2, p22.
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Gavin R Tait FRCSEd
Consultant Orthopaedic Surgeon Crosshouse Hospital, Kilmarnock Gavin.Tait@aaaht.scot.nhs.uk
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BJJ News | I ssue 3 | J une 2014
Letters
101 not out!
R. Owen R. Earlam
Clifford Brewer: Britain’s oldest surgeon and angler t the end of April Clifford Brewer, the oldest Fellow of our Surgical Royal Colleges (Fig. 1), celebrated his 101st birthday. We feel it appropriate that this extraordinary man should be remembered by young and old, partly because of his seniority among us, but more so by his remarkable war record over 60 years ago. When the last World War was declared, Clifford immediately joined the medical ranks of The British Army. He served as a field officer right through the war but when peace was declared he resigned forthwith to continue as a general surgeon in Liverpool. During his army service he excelled in the treatment of the multiply injured, despite his training in general surgery. While serving in Palestine as a major in charge of the sector hospital, he was called upon to evacuate 150 Vichy prisoners-of-war whose legs had been shattered by Free French guards in a riot. Clifford’s brilliant idea was to modify the Thomas splint as used by Robert Jones in The First World War by incorporating it in Plaster-of-Paris. This apparatus was later used in desert warfare during the El Alamein campaign and became known as the Tobruk Splint (Fig. 2). In retirement Clifford has enjoyed living on the family estate in Hampshire, fishing the Test for trout and tending the arboretum on the estate. His mind is clear as a bell but deafness bothers him and another disability which he calls ‘bugger’ is spinal stenosis, which makes fishing a burden. We salute our friend and wish him well in the evening of life.
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Fig. 1 Clifford Brewer, the angler, aged 10 0 (BBC Archive)
Robert Owen and Richard Earlam pay tribute to a remarkable man and his career.
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Fig. 2 Tobruk splint in the treatment of a femoral fracture,
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details
Robert Owen Richard Earlam
Robert Owen 41 Pwllychrochan Avenue Colwyn Bay Clwyd, LL29 7BW, UK