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Formerly known as JBJS (Br)
BJJ News | I ssue 5 | DECEMBER 2014
Issue 5
Orthopod’s view
Genetic Susceptibility Bridging the gap
A. Roposch
p2
Why Cambodia? D. Boot
p4
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WRIGHTINGTON HOSPITAL BASIC SCIENCE VIVA COURSE FOR FRCS (Orth) Tuesday 27 & Wednesday 28 January 2015
Course Convenors: Mr Sumedh Talwalkar & Mr George Pavlou This is an intensive course covering the essential aspects for Basic Sciences for trainees coming up to the FRCS (Orth) examination. Candidates are encouraged to apply early as this course is limited to the first 20 applicants. The format of the course will be similar to the highly successful Wrightington Hand Course with all teaching occurring in small groups as part of viva sessions and spotter sessions. In order to make the course as interactive as possible we have a very high faculty to candidate ratio. Participants will be encouraged to organize what they know on a given subject in a logical fashion in order that they can demonstrate their ability to present it succinctly. Course Fee: £350 includes course dinner, refreshments and buffet lunches Tuesday and Wednesday Further 2015 dates for this course: April, 14 & 15 September 15 & 16. For further details: please contact Jackie Richardson, Upper Limb Research Unit Wrightington Hospital, Hall Lane, Appley Bridge, Wigan WN6 9EP Email: upperlimb@wrightington.org.uk Telephone: + 44 (0) 1257 256248/6413 www.wrightington.com (Education) or www.wwl.nhs.uk (Our hospitals, Wrightington, Forthcoming Courses)
Orthopaedic Trauma Society 2nd Annual Meeting – 19 to 20 March 2015 We are pleased to announce the 2nd Annual OTS MeeDng. The OTS was established to be the focus of Orthopaedic Trauma debate, educaDon and research in the United Kingdom. Online booking will be open soon
Provisional Programme ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥
Update on the management of common fractures Case Discussions UK Trauma Delivery Update Guest Lecture: Prof Norbert Haas, Berlin Trauma Controversies: Debate Research Symposium Best of the Best Free Paper SecDon AGM
Venue: Warwick Conferences is situated at the University of Warwick. It is located 3 miles from Coventry and easily accessible by road, rail and air.
www.orthopaedictrauma.org.uk
Editorial
BJJ News
Role models
Issue 5
D. Jones
1
A. Rosposch
2
D. Boot
4
The British orthopaedic research
N. Hunt
7
society (BORS) Travelling
M. Al-Hajjar
Orthopod’s view Genetic susceptibility to disease
from The Bone & Joint Journal
December 2014
Bridging the gap Why Cambodia?
Fellowships
Fellowships 2014
P. Smitham
Notes from the road Current and Classic meeting
G. Monti
10
E. Di Vietro
Orthopaedic history Gathorne Robert Girdlestone
B. Fearne
12
F. Monsell
15
Dr San Baw; the man behind
B. Szostakowski
17
ivory hemiathroplasty
J.A. Skinner
and an early orthopaedic hospital - The Wingfield
Journal Office:
Orthopod’s view
22 Buckingham Street, London WC2N 6ET, UK
Jan Van Eyck and the Northern
bjjnews@boneandjoint.org.uk
Renaissance; a personal appreciation
Edited by: Mr David Jones Honorar y Consultant Or thopaedic Surgeon, London Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath
Advertising enquires: Dr Pam Noble ADmedica pnoble@admedica.co.uk
Orthopod’s Profile
Current practice Sporting injuries of the foot
M. Ballal
and ankle
J. Calder
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Letters 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)
The 2104 Vicary Lecture
D. Jones
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obituary Professor Louis Solomon 1918-2014
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John Fixsen 1934-2014
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Here is the (BJJ) News BJJ News is available to read online, in full and free. Catch up with the latest edition as well as previous issues at:
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BJJ News from The Bone & Joint Journal
A Bone & Joint publication www.boneandjoint.org.uk
BJJ News
Editorial
Role Models ne of my role models is 98 years old. Earlier this year he underwent a very successful total knee replacement (TKR) for intractable pain and deformity. He qualified in medicine in 1940 and spent most of the Second World War as an Army doctor in Burma, after which he set up in single-handed general practice in England in difficult circumstances, saw the introduction of the National Health Service in 1948 and, following retirement 30 years later, gave exceptional service to his community. The medical advances in his lifetime served him well in his long retirement. Thanks to bilateral cataract surgery, a pacemaker, prostatectomy, TKR, hearing aids, dentures, other minor operations and now, with home care, a stair lift and a mobility scooter, he is spending his seventh age in a manner which Shakespeare could not have imagined. It has always been educational and usually fun to share and reflect on our combined experiences covering more than 70 years. Although we read different newspapers, mine further to the Right than his, we shared similar values in our duties and responsibilities for patients and their families in our care. These have not changed in our lifetimes. It is obvious that things were not as good in his day. Working often in difficult conditions with poor resources, it is those principles that were fundamental to helping his patients and himself through good and bad times. It is his strong advice that we should not lose them in spite of all the changes in and around Medicine generally. To my knowledge, very little of his life’s work is in print and it is only through conversation and seeing first-hand the respect by which he is held in his community, that one can appreciate his contributions. I have other role models in surgery whom I respect not only for their technical skills but also their industry, probity and dealing with adversity. This respect was
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gained by seeing them in action and in my career I hope I was able to hand on some of the lessons from my seniors alongside useful experience of my own. The next generation are facing different experiences and challenges, many insoluble in their complexity. It is easy to write sanctimonious prose and equally unhelpful for young doctors to hear from some old codger that ‘it was much better in my day’. They are bright and savvy enough to pick up and run with what’s useful. It is hoped that BJJ News reflects much of the above. Alistair Ross and I aspire to complement BJJ, BJR and BJ360 by stringing together articles of interest in the history, progress, personalities and events in our specialty. As we move into our second year of publication, it is a time for reflection and evaluation of our progress. We are reasonably content but not complacent and welcome outside opinions on the matter. In this issue, San Baw’s pioneering work on ivory arthroplasty in Burma, whereby a concept was delivered successfully into clinical practice in a low-tech way and without a p-value in sight, can be compared with the latest in genome research, which requires large numbers of cases and controls, high-tech laboratory input and mind-boggling statistical analysis. Among other contributions, we mark the passing of two outstanding orthopaedic surgeons, report on how one orthopaedic surgeon mixes art with work, hear of a successful charitable project in Cambodia, receive an historical vignette from Oxford and learn about ankle injuries, all alongside regulars such as news of events, fellowships and letters. With an ever-expanding knowledge base and inevitable sub-specialisation, it is important we don’t lose ourselves in the distal leaves of the tree and forget the roots and branches which carried us there.
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BJJ News | I ssue 5 | D ecember 2014
Orthopod’s view
Genetic susceptibility to disease
A.Roposch
Andreas Roposch explains how current research is working to determine the influence of genetic factors in diseases in general and orthopaedics in particular ommon diseases such as osteoar thritis, diabetes and cardiovascular disease are typically caused by an interaction of multiple genetic and environmental factors.
map of a population which shows the position
who do not display this outcome (the controls).
of its known genes relative to each other in
In a genetic association study, the outcome of
terms of recombination frequency. Linkage
interest is a particular disease (phenotype),
mapping is critical for identifying the location
ideally defined by robust diagnostic criteria.
of genes that cause genetic diseases. Over
By comparing a very large variety of genetic
4000 human single-gene disorders are known,
variants between cases and controls, scientists
The former also influence phenotypes
many of which are relevant to orthopaedics.
can pinpoint which variants distinguish cases
such as blood pressure, height or body
For example, Duchenne muscular dystrophy
from controls. For each genetic variant or
mass index. For example, it is intuitive that
is an X-linked recessive disease. As such, male
marker examined, an odds ratio is derived;
consuming fried food – an environmental
carriers of the gene are always affected by
it quantifies the strength of the association
factor – will raise a person’s body mass index
the condition whereas females, having two
between the genetic variant and the disease of
(BMI). However, having a particular genetic
copies of the X chromosome, are not. Another
interest.
makeup can increase this risk. In a recent study
prominent single-gene disorder relevant to
There are two broad approaches to genetic
from Boston1 the combined genetic effect
orthopaedics is hypophosphataemic rickets. It
association studies. They can focus on candidate
on BMI among individuals who consumed
is also X-linked but follows a dominant trait –
genetic markers, in which the testing follows
fried foods more than four times a week was
males and females are both affected, with males
an a priori hypothesis about which parts of
about double that of those who consumed
typically presenting a pronounced phenotype.
the genome could play a causative role. The
such foods less than once a week. Therefore,
For complex diseases, which are not
hypotheses are established on prior knowledge
a healthy diet and lifestyle in individuals with
caused by a single gene mutation but by
or hypotheses of genetic influence on disease
such genetic factors is a potential preventative
an interaction of several genetic factors in
causality or pathways. Collaborative databases
strategy in controlling the risk for obesity. This
addition to environmental factors, other
exist that contain up-to-date knowledge on
illustrates how information obtained from
approaches are needed to delineate the
genetic epidemiology, which allow such
genetic studies can be useful in clinical care.
genetic susceptibility for developing a disease
hypotheses to be formed and tested in either
Besides understanding the causes of disease,
or a particular manifestation of it. The matter
de novo studies or meta-analyses.
an understanding of modulators of disease
is complicated because for complex diseases,
Conversely, in a genome-wide association
progression and susceptibility for cer tain
each genetic variant usually makes only a
study (GWAS), there is no a priori hypothesis:-
manifestations of diseases is critical for many
modest contribution and will generally have a
the entire genome is searched for genetic
conditions. It allows us to make prognostic
small effect on the risk of disease. The typical
markers possessed by cases but not controls.
inferences and establish risk groups for whom
frequencies of variants that underlie common
Because a GWAS surveys most of the genome
care can be tailored in cost-effective ways. The
disease are largely unknown, but those
for genetic variants shared by cases without
delineation of genetic factors associated with
with frequencies > 1% in the population are
making assumptions about the genomic
common diseases can have important clinical
considered to influence susceptibility to disease.
location of the causal variants, this approach is
implications for the effective treatment of
Because the genetic factors interact with each
suitable even in the absence of evidence about
these conditions, and the implementation of
other, and because there is also interaction
the location of genes that cause a disease.
strategies to prevent the development of sever
between genetic and environmental factors,
Typically GWAS search for single-nucleotide
forms of that disease.
unravelling the genetics of such diseases is a
polymorphisms (SNPs). A SNP is the most
complex matter.
common of all DNA sequence variations
C
Unlike common diseases, rare disorders are
2
typically caused by a single gene mutation
One approach to identify causative
occurring within 1% of the population. In a
which is usually identified by linkage analysis
genetic risk factors of these diseases is to search
SNP, a single nucleotide (Adenosine, Thymine,
of affected members in a family. Genes that are
for an association between a specific genetic
Cytosine or Guanine) in the genome differs
located close to each other on a chromosome
variant and a particular disease using a case-
between members of a biological species or
a re l e s s l i ke l y to b e s e p a ra te d d u r i n g
control study design. In this, a sample is drawn
paired chromosomes. For example, some
chromosomal crossover. They are said to be
from a population of interest and probands
chromosomes in a population may have a T
genetically linked and are therefore likely to be
displaying the outcome of interest (the cases)
at a certain site, whereas others have a C. The
inherited together. A linkage map is a genetic
are compared with probands in this sample
systemic arrangement of an SNP can only detect
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shared genetic variants that are common to
for claiming statistical significance a genome-
The efforts of GWAS can be enormous
many individuals in the wider population. They
wide association study. This is equivalent to a
and these studies are often criticised for
can be identified directly, where each putative
p-value of 0.05 after a Bonferroni adjustment
being expensive. An example to illustrate
causal variant is tested for correlation with the
for as many as 1 million independent tests.
the efforts that go into GWAS is inflammatory
disease of interest.
Replicating studies, which are necessary to
bowel disease. Based on GWAS, advances in
Because this approach is costly and time
validate the results of de novo GWAS, require
understanding this disease have been made over
consuming, an indirect approach has been
even higher numbers of participants. Many
a period of two decades and included 20 000
developed. This involves the identification of
adequately powered de novo GWAS were based
patients with Crohn’s disease, 15 000 patients
a set of sequence variants in the genome that
on 6000 cases and 6000 controls. Collaborative
with ulcerative colitis and 25 000 controls,
serve as genetic markers to detect association
initiatives among several clinical units are thus
amounting to 60 000 participants in 15 separate
between a particular genomic region and the
essential in order to recruit an adequate number
GWAS. These identified 163 independent genetic
disease, regardless of whether the markers
of patients in a timely fashion.
risk loci, based on genotyping 200 000 SNPs.
have functional effects. This approach allows
Another critical issue is the definition of
Despite the large number of participants, the
the search for genetic variants to be limited to
disease. Robust diagnostic criteria are essential
risk alleles found only explained modest risk for
regions of the genome that show association
in defining cases and controls. Ideally, there
disease, with odds ratios ranging from 1.05 to
with the disease. The SNPs to be genotyped are
1.5. An important finding, however, was that
chosen on the basis of linkage disequilibrium
67 of these risk loci were shared by Crohn’s
patterns to provide information about as many
disease and ulcerative colitis, which in itself
other SNPs as possible. Linkage disequilibrium is
opens new avenues in researching the cause of
an expression of the correlation between nearby
inflammatory bowel disease.
variants. Most of the genome falls into segments
There are a number of such studies
of strong linkage disequilibrium, within which
relevant to orthopaedics. Successful examples
variants are strongly correlated with each
include arcOGEN,3 a GWAS that involves 11
other. Based on known linkage disequilibrium
centres in the UK with the aim of identifying
patterns, establishing the location of one SNP
the genetic determinants of osteoarthritis,
will therefore automatically identify which other
and the DDH Case Control Study,4 a national
SNPs are nearby. The International HapMap
collaboration of 20 paediatric orthopaedic
Project2 specifies the common patterns of DNA
centres to perform a GWAS in children with
sequence variation in the human genome. This
congenital hip dysplasia. The logistics of GWAS
database allows scientists to pinpoint sequence
can be challenging. They require a high degree
variants, their frequencies and how they are Fig. 1 A gene is a def ined, locatable region in the double helix structure of correlated. DNA . Introns are the regions in Exome sequencing has recently gained genes that are removed af ter the popularity. In contrast to GWAS which concerns DNA is transcribed into RNA . E xons are the regions which the whole genome, exome sequencing is a encode the protein. GWAS look for technique for sequencing all the protein-coding polymorphisms at both exons and genes of the genome (Fig. 1). Exomes make up introns, whereas exome sequencing for 1% of the human genome but mutations only focuses on the par ts of the genome made up by exons. in this part of the genome are perhaps more
of precision in collecting cases with accurate
likely to have consequences compared with
should be a consensus among clinical experts
recruiting patients and completing studies on
mutations in the remaining 99% because
as to the definition of disease, especially in
time.
exomes are directly related to gene products.
situations where there is clear cut-off between
Exome sequencing aims at identifying variants
normal and diseased. The safest approach is to
in exomes. Whether concentrating on this 1%
use the most severe phenotype in defining cases
of the genome has the potential to unravel a
but often this phenotype is rare, making studies
high yield of relevant genetic variants remains
much harder to execute because recruiting such
to be seen.
cases could require impractically long periods.
The clinical implications of genome-wide
It is important to emphasise that GWAS studies
association studies are promising but they pose
detect association and not causation. However,
challenges. As GWAS usually identify modest
the cumulative effects of multiple SNPs can be
risk ratios, they require a large sample size,
used to explain a fraction of an individual’s risk
especially as the assumed minor allele frequency
for the trait. Results from GWAS can be further
is small. Also, GWAS rely on multiple statistical
tested in the laboratory to pinpoint disease
testing, which further inflates the sample size.
causality.
A p-value of 5 x 10-8 is a conservative threshold
phenotypes in a timely fashion, adequate support of surgeons in obtaining consent and saliva samples. In particular, funding is needed to allow recruitment at multiple sites. Such support has recently been promoted by the National Institute for Health Research Local Research Networks,5 which aim to provide support for local NHS Trusts in effectively
Reference
1. Qi Q, Chu Ay, Kang JH, et al. Fried food consumption, genetic risk, and body mass index: gene-diet interaction analysis in three US cohort studies. BMJ 2014;348:g1610. 2. No authors listed. NCBI. http://hapmap.ncbi.nlm. nih.gov (date last accessed 11 November 2014). 3. No authors listed. arcOGEN. http://www.arcogen. org.uk/ (date last accessed 11 November 2014). 4. No authors listed. UKCRN. http://public.ukcrn.org. uk/search/StudyDetail.aspx?StudyID=11784 (date last accessed 11 November 2014). 5. No authors listed. NIHR. http://www.crn.nihr.ac.uk (date last accessed 11 November 2014). A uthor
details
Andreas Roposch, MD MSc FRCS Great Ormond Street Hospital for Children, UCL Institute of Child Health a.roposch@ucl.ac.uk
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BJJ News | I ssue 5 | D ecember 2014
D. Boot
Bridging the gap
Why Cambodia? Dalton Boot describes a long-term project to improve orthopaedic care in Cambodia EGINNINGS Eleven years ago, while working in an NGO Hospital in Phnom Penh, Cambodia, Tim Keenan, an Australian colleague and I began to work with a government hospital which had a large orthopaedic/trauma unit. The reason we chose this hospital was because a dynamic head surgeon and the Hospital Director had asked for our help to improve the unit. We began regular teaching visits for the surgeons; but it soon became apparent that for this teaching to be effective and for the quality of care to improve, we needed to reach a broader group than just the surgeons. Because of the political disruption in the Pol Pot era and for some years afterwards, the ward and theatres had not been renovated. Most of the nurses had undergone no formal training and there was a serious lack of surgical equipment. Not surprisingly, morale was poor.
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So, how could we help? Despite its shortcomings, the ward was the busiest orthopaedic trauma unit in the capital, Phnom Penh, and its patients deserved a better quality of care. Clearly, money, knowhow, equipment and training were needed. Without the experience of knowing how best to meet these needs, it was not possible for us or for the hospital to make a long-term plan. So we decided on a step-by-step approach with a semioptimistic outlook. Around this time, we suggested to the head surgeon that he consider copying the Edinburgh tradition of daily 8am trauma meetings. To our surprise, this was organised within two days (Fig. 1) Morale improved immediately because the meetings resulted in better communication and organisation within the unit. They continue to this day. All this impressed the director of the nearby NGO hospital who then obtained a grant from USAID. This helped, partially, to renovate the ward and theatre, fund
Fig. 1 The 8am meeting
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some new equipment and start some early nurse training. The Director at the government hospital also helped to improve infection control by using the limited budget to assist with other items. This modest improvement started to represent a gradually improving clinical situation which could be used to motivate other donors. Smith and Nephew, and other companies, donated second-hand fracture sets and instruments which made a significant improvement to surgical care. World Orthopaedic Concern UK helped with a contribution to airfares, and a UK charity, World Jewish Relief, lent their paid fund- raiser, who had special expertise in how best to approach specific UK Trust Funds for donation to a medical project in a developing country. In the first year of fund-raising, a modest amount of money was donated. This was used to pay, partially, for a senior theatre nurse who would be responsible for all surgical equipment (almost none has been lost over many years), also, for a
Fig. 2 Good organisation by Miss Dalys, Or thopaedic Coordinator
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Fig. 3 Mar y Wood, Or thopaedic Sister from UK , taught for nine months
Cambodian lady who was employed to start managing the local finances and to furnish the growing need for good organisation of the project (Fig. 2) A donation from World Orthopaedic concern UK also funded a senior orthopaedic nursing sister from the UK who came to the hospital for 10 months to train the nurses and start an orthopaedic curriculum (Fig. 3) Her hands-on personal training taught good UK nursing practice and greatly improved the quality of nursing care. By this time, after several years, surgeon and nurse training, improved cleanliness and infection control, together with the renovation of the ward and theatre had greatly improved morale. Furthermore, a good relationship, with trust and understanding, had been gained on both sides. The project could only progress if the hospital director and head surgeon wanted and promoted an improvement, and participated in each step. Further Progress: a new building and Reconstructionon Surgery Unit. The years of improvements had clearly been noticed by the patients; so much so that the ward had become severely overcrowded. After obtaining letters of understanding from the hospital, it was decided to try to finance the building of a new ward to expand the trauma service and develop the first government orthopaedic reconstruction surgery unit. The steady reports of positive progression of the
quality and quantity of care had given UK and Australian donors the confidence to continue and increase their donations. After finding a competent builder and overcoming building regulations, the new building was completed in two years (Fig. 4). This allowed the new reconstruction surgery unit to develop in part of the new building, where treatment could be offered for adults and older children with severe deformities from polio, club foot, trauma to other causes. Dr Ry Sina, an experienced Cambodian surgeon, who we funded to train at a renowned reconstruction unit in India, and who also trained in France, became the lead surgeon. This unit is working well with dual funding from the hospital and the project: many patients have now been treated (Fig. 5). Project to improve f ive Provincial Government Hospitals. Following the improvement at the Kossamak Hospital, it was decided to explore the condition of the various government hospitals around Cambodia which had functioning orthopaedic units. Five hospitals with a dynamic director and head surgeon were chosen. All these hospitals lacked both surgeon and nurse training, essential ward and theatre equipment and implants. With the exception of one hospital, which had a newly built unit funded by the Japanese, all had run-down wards with poor infection control. Using the example of the NGO hospital, several of the provincial hospitals
had ward renovations and some building works; in one case a new ward was built. Also, six-week up-date training courses were organised for the provincial surgeons and nurses. When training had been completed, and infection control improved, surgical implant sets and instruments were donated. These were only donated with a written agreement from the hospital that used implants would be purchased and replaced by the hospital. A reputable Indian Company was chosen and a financial replacement system organised. This system has now continued over several years. Improvements in infection control and quality of care have continued. Nurse training had also continued with annual meetings. A modified UK nursing curriculum has been approved by the MOH and is taught to most of the existing nurses and student nurses qualifying from the nursing schools (Fig. 6). The Orthopaedic Committee (SOCOT) The Cambodian Orthopaedic Society Committee consists of about six senior surgeon members and the society has several dozen surgeons who have been trained in France and various other countries. At the committee’s request, we collaborated to discuss possible improvements in Cambodia’s Orthopaedic services and effectiveness of the SOCOT committee. With the help of the Project’s Orthopaedic Coordinator we assisted with the organisation and funding of monthly meetings and annual special
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BJJ News | I ssue 5 | D ecember 2014
meetings, helping to obtain and fund international speakers, and the organisation of the membership and collect ion of subscriptions. Only those projects approved by the committee were pursued. Have the aims of the Project been fulfilled? The aims of the Cambodian Project were first to work with the most dynamic surgeons and nurses and administrators available, to help them develop orthopaedic services with some certain advice from ourselves, but mostly according to their wishes. Second, to leave most of the project work in as sustainable a state as possible. This included significant surgeon training at six hospitals; nurse training at 12 hospitals, MOH-agreed introduction of a UK nurse curriculum for student nurses; new ward constructions at two hospitals, provision of implant and instrument sets with a sustainable replacement system, an improved orthopaedic society with their
own better management, a Cambodian-run government orthopaedic reconstruction unit with now only modest help from funding, an annual nurse meeting (now running for three years) with modest help from funding and, with the help of an Indian orthopaedic implant company, low-cost but clinically acceptable implants. Supplies to most government hospitals and clinics have replaced unpredictable supplies available from the market. In conclusion, sustainable improvements have been made. These are not always perfect but they are, according to the members of the Orthopaedic Committee, significant. Partial payment of three temporary nurse salaries will continue for a limited period. To maintain the reconstruction unit, a much reduced payment, shared with the hospital will also continue for a limited period. Hopefully, some lessons learnt from this project may be applicable to other hospitals in developing countries to help them
improve their orthopaedic services in a financially modest and sustainable manner. The BOA with its highly experienced and motivated membership, organisation and influence may also have a greater role to play to assist our many colleagues working in less privileged countries. This project has required long-term commitment, now 12 years, with the hands-on involvement of two surgeons, who at times worked in Cambodia for separate four-month periods to maintain continuity. When in UK or Australia, we interacted frequently with colleagues in Cambodia and the project-paid orthopaedic coordinator. The work of a committed and knowledgeable fund raiser in the UK, and donors in Australia were also essential. Although at times it was difficult and thought-provoking to work in a developing country, the interaction with motivated colleagues was very rewarding. The need for this cannot be overstressed.
Fig. 4 The new ward and out-patients depar tment Fig. 5 Children from Lavala school attending for pre- and postoperative assesment
A uthor
details
Dalton Boot Deputy Chairman of World Orthopaedic Concern UK daltonboot@waitrose.com Fig. 6 Af ter their teaching course, proud nurses with their cer tif icates
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N. Hunt M. Al-Hajjar P. Smitham
Fellowships
The British Orthopaedic Research Society (BORS) Travelling Fellowship 2014 Around the world with three up-and-coming orthopaedic researchers
Fig. 1 First Stop – Mazen, Peter and Nicola at the ORS Annual Conference, New Orleans he Brit ish Or thopaedic R e s e a r c h Tr a v e l l i n g Fellowship is a biennial award of fered to a bioscientist, bioengineer, clinician and allied health professional who are within their first five years of completing a PhD/ MD. This prestigious opportunity was started in 2007 and enables researchers early in their careers to visit a variety of centres around the world to identify different laboratory techniques and develop collaborative opportunities. On 14th March, 2014, three BORS travelling fellows embarked on a fiveweek world tour. This year’s fellows were Nicola Hunt, a research scientist from Newcastle University, specialising on hydrogels as scaffolds for tissue engineering and biomechanics of the normal and replaced knee, Mazen Al-Hajjar, a research engineer from the University of Leeds (tribology of hip joint replacements) and Peter Smitham, an orthopaedic registrar and
T
Fig. 2 Morning group meeting at HSS , New York, hosted by Prof. Matthias Bostrom.
clinical lecturer from University College London (improving fracture fixation with propranolol in animal models, ankle fracture fixation techniques and muscle fatigue in elite football players). We began in New Orleans, where we attended the ORS meeting (Fig. 1) The conference offered a range of talks and posters in each of our disciplines. We were able to hear about developments in our respective areas of expertise, network and meet with exhibitors and potential collaborators. The workshops provided advice and information on journal publication, grant-writing and publicity to enhance our career success. This year, we were encouraged to use free time between scientific sessions and workshops for networking. Part of the programme included ‘p o s t e r w a l k i n g t o u r s ’ l e d b y experienced investigators, encouraging discussion between different delegates from around the world. This great new addition generated some lively
discussion regarding project designs and potential future projects. The meeting also focused on researchers early in their careers by providing opportunities for further career developments. After the ORS, we flew to New York where we visited three different centres arranged for us by Professor Mathias Bostrom. During the week we attended lab meetings, presentations and met with scientists and surgeons from a range of disciplines to discuss their research and how it might translate to clinical practice. We presented our work at the three institutes, generating a wealth of discussion and debate. We shared informal discussions on establishing an academic career in orthopaedics, sharing our thoughts about career prospects and funding. Through this meeting we received valuable advice and support from some of the most experienced professionals in the field.
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BJJ News | I ssue 5 | D ecember 2014
Fig. 3 Enjoying a bike ride with Prof Gerald Atkins on our free af ternoon at the Eighth Clare Bone Meeting, Clare Valley, Australia.
The first centre we visited in New York was Mount Sinai Hospital. We were warmly welcomed to their School of Medicine by Prof. James Iatridis who is a very active and internationally renowned spine researcher. His team provided a comprehensive overview of their research. Of particular interest was their mucopolysaccharidosis mouse model which can potentially provide useful insights into the effect of proteoglycan quality on disc structure, morphology and biomechanics. The second centre in New York was Columbia University where our host, Dr Francis Lee gave us an exciting tour around the hospital and chaired a meeting where we presented to invited surgeons and scientists. The pressure to optimise space in the metropolis was emphasised and the new facilities were very impressive. Our last port of call in New York was the Hospital for Special Surgery (HSS, Fig. 2) where, following a visit to their animal facility, Professor Tim Wright at the department of biomechanics impressed us with their strong history of collecting
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explants from patients after their revision operat ions, thereb y generat ing a considerable retrieval database. As 10% of more than 8000 arthroplasty operations annually at HSS are revisions, up to 800 implants per year are banked for analysis. Prof. Howard Hilstrom, Director of the Leon Root Motion Analysis Laboratory, demonstrated the 12-camera motion analysis system used for clinical and research information. This laboratory has been designed to allow flexibility in forceplate and camera placement and hosts a range of equipment including four force platforms, an electromyography system and a gaitmat II and pedography system to measure foot pressure distribution. He also demonstrated results of knee kinetics and kinematics using an instrumented ‘eTibia’ prosthesis. Professor Mathias Bostrom arranged a New York Style dinner for us at the Union Club, East 69th Street and Park Avenue, one of the oldest private social clubs in New York, founded in 1836. We met investigators from HSS, University of Columbia and Mount Sinai Hospital. At this informal gathering, Peter
and Prof. Adele Boskey discussed their mutual interest on muscle fatigue in elite sportsmen and Prof Bostrom highlighted the impor tance of developing collaborat ions, hence has weekly Skype meetings with other centres. After New York we flew to Adelaide where we were hosted by Prof. David Findlay, from the University of Adelaide. We had the opportunity to visit the laboratories of Prof. Findlay and Assoc. Prof. Gerald Atkins to gain insight into their work on osteoclasts, osteocytes and osteoblasts in bone remodelling. We also saw the studies and laboratories of biomechanical engineers Dr. Claire Jones and Dr. Dominic Thewlis, from the University of Adelaide and neighbouring University of South Australia. We each gave presentations at the Adelaide Bone Group Meeting and attended the Eighth Clare Bone Meeting, a few hours drive from Adelaide. The relatively small interdisciplinary meeting in Clare Valley allowed interaction and knowledge acquisition from clinicians, engineers and scientists from Australia and international researchers.
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The hosts made sure we enjoyed our stay, with a wine tour on bikes around Clare Valley (Fig. 3), a visit to the wildlife park in Adelaide and a BBQ at Prof. Findlay’s house. We then travelled from Adelaide to Hong Kong where our hosted was Prof. Ling Qin. We were given a tour of the laboratories and facilities of The Chinese University of Hong Kong (CHHK) and Prince of Wales Hospital by Prof. Gang Li (Fig. 4). The hosts arranged a meeting where researchers from Hong Kong and ourselves presented, followed by a banquet hosted by Prof. Ling Qin. In particular we learnt about the work at CHHK on biomaterials, bone-tendon junction repair, stem cells and fracture healing. A relatively short flight later we landed in Shanghai, a city of contrasts and often described as the beating heart of China. We visited a number of centres including the Shanghai Institutes for Biological Sciences, the Engineering Research Centre of Digital Medicine and Clinical Translation and the Med-X Research Institute of Shanghai Jiao Tong University
(hosted by Prof. Gu Dong-yun) where one of the projects was looking at the 3D printed pelvis in trabecular metal. In the afternoon we went across town to the orthopeadic department in Shanghai Ninth People’s Hospital where Prof. Ting Tang and his colleagues showed us some clinical studies, including those related to the challenges in sizing knee implants with their patients’ knees and we discussed some of our projects. The day ended with a sumptuous Chinese banquet sampling some of the fine delicacies Shanghai had to offer. We had the opportunity to discuss the research culture within Shanghai with local junior academics and visited some of the exciting sites in Shanghai including the State Circus. A day later we were back on the move, flying to Berlin. Here we were hosted by Prof. Georg Bergmann and greeted by Verena Schwachmeyer (Fig. 5). A fantastic programme of activities and events had been organised for the following few days. We were given the opportunity to see a plethora of cuttingedge projects investigating stem-cell activity, instrumented implants, bioactive
Fig. 4 Prof. Gang Li showing us around the Chinese University of Hong Kong. A uthor
implants, fracture healing techniques and the latest in imaging. We continued our research discussions during the weekend while on a cycle tour of East Berlin and had time to visit the Sunday karaoke extravaganza of Mauerpark. Throughout the trip we were able to share our research findings with leading scientists from around the world and gain a vast amount of knowledge from the researchers we met and the conferences we attended. The fellowship is sure to lead to future collaborations between ourselves and the host organisations, as has been the case for past fellows. Interestingly, throughout the trip we were repeatedly asked by our hosts “why isn’t this opportunity offered by other national orthopaedic research societies?” We don’t know but we are eternally grateful to the hospitality of all the host organisations and the financial support of BJJ and BORS for providing this amazing opportunity and insight into the different research activities, teaching and training styles and laboratory setups around the world.
Fig. 5 Lunch with Prof. Georg Bergmann and Verena Schwachmeyer from the instrumented implant group at Charité, Berlin.
details
Nichola Hunt, Research Scientist, Newcastle University . Mazen AL- Hajjar, Research Engineer, University of Leeds. Peter Smitham, Orthopaedic Registrar, University College, London petersmitham@gmail.com
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BJJ News | I ssue 5 | D ecember 2014
Notes from the road
F.Burgo C.Autorino
Current and Classic Meeting
Gabriela Monti and Enrique Di Vietro report on the Sixth Inter national Annual Meeting of Hip and Knee Reconstr uctive Surger y at Austral University Hospital.
T
he a dult Reconstructive Surgery Service of H o s p i t a l U n i ve r s i t a r i o Au s t r al organised the latest ‘current and classic’ course under the
chairmanship of Carlos M. Autorino MD, Federico J. Burgo MD and Diego E. Mengelle MD. The course is endorsed by the Argentine Or thopedic and Traumatology Association’s Medical Education Committee and sponsored by the Argentine Association for the Study of the Hip and Knee. Hospital Universitario Austral is a Joint Commission International-accredited Academic Health Centre (Fig. 1). The course is devoted to exploring topics about
Fig. 1 Hospital Universitario Austral, Buenos Aires, Argentina.
the hip and knee joints and brings together a faculty of experts from local, national and international centres to present and discuss the best available clinical evidence (Fig. 2) Previous international guests have included Aaron Rosenberg, Thorsten Gehrke, Javad Parvizi, John Timperley, Matthew Hubble, Jay Mabrey, Michel P. Laurent, Mario Mercuri, Christoff Berberich, Franco Bertoni, Olivier Tayot, Paolo Alencar, Rogerio Fuchs and Manuel Villanueva Martínez. This year the international guest speakers were John D. Blaha, Fares Haddad, Bernard Stulberg, Thorsten Gehrke, Günther Lob, Alberto Fernández Dell‘Oca, Justino Menéndez and Fernando Motta. The programme concentrated mainly on the following: 1 Analysis of the 2013 Philadelphia Consensus (PC) on
Fig. 2 Faculty and delegates in session
periprosthetic infections 2 Degenerative joint disease: its natural history and predictors of unfavourable progression 3 Thromboembolism, blood transfusion and pain relief after joint replacement surgery. 4 The unstable THR, periprosthetic fractures and
c) Weak consensus (“majority”)
Nevertheless, he granted that the PC could become an important tool for experts involved in medical liability.
d) No consensus
The debate on periprosthetic infections (PPI)
b) Strong consensus (“supermajority”); 202 questions attained this type of agreement
involved experts in reconstructive hip and knee
segmental bone defects 5 Outcomes assessment and national registries. 1. 2013 Philadelphia Consensus (PC) on Periprosthetic infections A total of 207 questions were analysed by the PC. The power of agreement among experts was classified according to the scale of consensus: a) Unanimous consensus (only one disagreement in this category)
10
The PC also identified topics requiring further investigation. Primitivo H. Burgo MD, PhD, an orthopaedic surgeon and expert in forensic medicine, analysed the concept of “consensus” from a medico-legal perspective. He stressed that the conceptual definition, namely that consensus is a practical guide drafted by experts, is not a standard of care and statements should never be used in isolation to define liability.
surgery as well as microbiologists. Two of the relevant topics were organisms multi-resistant to antibiotics and fungal infections. R. Quirós MD, F. Nacinovich MD and G. Kremer MD analysed the causes of multidrug resistance in bacteria and identified standard preventive measures. L. Carbó MD presented an extremely unusual series of 30 cases of mucormycosis secondary to arthroscopic ACL reconstruction. The diagnosis
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was made in late in all cases as Mucor infects the
3. Joint replacements: highlights on internal medicine
of the coupling system was also presented. This was
bone marrow and was therefore missed by the
and clinical complications
resolved using the ‘cement-on-cement technique’
arthrocentesis performed at the onset of the
a) DVT prevention protocols.
which had earlier proven successful in the revision
arthritis. All cases were solved with two-stage
Prospective, randomised, multicentre studies on the
of polished tapered stems. The procedure was based
segmental reconstructions.
incidence of thromboembolic complications have
on the quadrangular pyramid profile of the hinged
confirmed the effectiveness of low molecular weight
implant stems.
J. Menéndez MD described the key points of systematic debridement and its technical principles. D. Mengelle MD described the operative technique
heparin compared with other pharmacological
In a session on complex acetabular reconstruction,
strategies such as Warfarin.
F. Burgo MD explained step-by-step the critical
and outcomes using articulating hip spacers as a
b) Strategies to reduce blood loss in Hip and Knee
aspects of the operative technique and showed the
definitive procedure in patients with a short life
replacement.
results of impaction bone grafting applied to complex
expectancy or significant comorbidities.
Various ways of optimising the pre-operative
uncontained acetabular defects using morsellised
F. Haddad MD showed good outcomes of one-
haematological status, identifying patients at risk of
fresh bone allograft and wire mesh at six years
stage treatment for PPI, based on a simple but strict
developing symptomatic post-operative anaemia and/
follow-up.
protocol.
or related complications were discussed.
F. Motta MD explained the causes for instability
T. Gehrke MD explained the current Endoklinik
H. Caviglia MD reported the experience of one of the
protocol on the scheme and type of antibiotic
largest international case series of hip replacement in
treatment for PPI.
haemophiliac patients, treated jointly with the team
5. Outcomes assessment, national registries and
of experts from The National Academy of Medicine.
ICUC.
2. Degenerative joint disease: natural history and
c) Multimodal approach for prevention and treatment
F. Haddad MD analysed the strengths and weaknesses of
predictors of unfavourable progression
of post-operative pain in TKR.
national registries. Notwithstanding their clear benefits,
It was agreed there were few international studies on
B. Stulberg MD showed that multimodal strategies,
certain weaknesses should not be overlooked, for
the natural history of osteoarthritis.
including local anaesthetics (liposomal bupivacaine) in
example, using revision as an end-point. The creation of
Although MRI and arthroscopic assessment are
the operative field improves quality of life and reduces
data collection files which include assessment of residual
currently considered to be the gold standard for
length of stay; also, limiting opioids made it possible to
pain and patient’s satisfaction could be an opportunity
assessing the state of articular cartilage, neither of
prevent adverse events from their side effects.
for improvement.
these procedures identifies the very early stages
and malalignment of the extensor mechanism
J.D. Blaha MD described the “forgotten knee”,
of joint damage, when evidence shows that the
4. Unstable THR, periprosthetic and segmental bone
emphasising that the medial pivot designs reproduce
fundamental substance is involved.
defects
natural function more accurately than the traditional
H. Caviglia MD presented a classification of hip
“roll back” and posterior stabilisation theory.
Biomarkers (e.g.: glycosaminoglycans) are better possibilities for an early diagnosis.
abductors and described a reconstructive technique
D.Stulberg MD identified a major advantage in using
S t u d i e s we re p re s e n t e d s h o w i n g t h a t
using Vicryl and Prolene mesh. Encouraging results
compression-moulded inserts and the possibility of using
femoroacetabular impingement and gonarthrosis
were presented in a series of patients with post-
more effective locking mechanisms to reduce wear.
are predictors of an unfavourable prognosis in
traumatic sequelae, revision joint replacement and
osteoarthritis
arthrodesis conversion.
F. Dell’Oca MD presented a free-access application for Mac (ICUC: “I see you see”; www.icuc.net) which
The course organisers, using a histotechnical
G. Lob MD described ways of treating severe
contains a “step by step” documented database of
protocol, investigated the histology of normal-looking
segmental bone and joint defects resulting from
traumatic pathology and outcomes scored by an
chondral areas in a TKR resection block and showed
trauma, infection, osteolysis and iatrogenic bone
independent expert and anonymous observer. One of
very interesting experimental evidence of chondral
loss. The ‘bonebridge’ designs are also indicated
the fundamental pillars ICUC is its strict registration
involvement in those areas.
in selected cases of orthopaedic oncology (e.g.
protocol.
The researchers found a statistically significant
pathological diaphyseal fractures), knee arthrodesis
The 7th Current and Classic meeting will be held
correlation between “meniscal extrusion of more
and interprosthetic fractures with fixed implants,
at Hospital Universitario Austral on July 23/24, 2015.
than 3 mm, diffuse bone marrow oedema and
whereby the device is interposed between the ends
The focus will be on surgical challenges relevant
chondral involvement”, which makes it reasonable
of the prosthesis, close to the fracture site.
to everyday practice, including alternative bearing
to consider them as predictors of unfavourable
Professor Gehrke described the large variety of
surfaces; the painful knee replacement; allergy
progression in OA. Some practical applications
modular devices currently available in the hinged
as a cause of failure; new trends in the diagnosis
include: a) understanding why in certain patients
and rotational hinged implant systems designed by
and treatment of periprosthetic infections; joint
,radiological images are inconclusive despite
Waldemar-Link NR (Hamburg). He and C. Autorino
kinematics; prevention of dislocation; tribocorrosion;
persistent and progressively disabling symptoms;
MD explained the failure mechanisms of rotational
femoroacetabular impingement; the best operative
b) indicating earlier reconstructive surgeries
systems in incorrectly chosen cases, and described
techniques and update on megaprostheses;
and avoiding long and unwarranted conservative
the intra-operative findings in a revision operation.
optimisation of fixation methods and a keynote
A case of mechanical failure of the plastic lining
session on medical liability in total joint replacement.
treatments.
A uthor
details
Federico J Burgo MD: burgof@hotmail.com Carlos M Autorino MD
11
BJJ News | I ssue 5 | D ecember 2014
Orthopaedic history
B. Fearn
Gathorne Robert Girdlestone and an early Orthopaedic Hospital – The Wingfield.
Fig. 1 G.R . Girdlestone athorne Robert Girdlestone (GRG, Fig. 1) was born in 1881 to the Reverend Robert Baker Girdlestone, Honorary Canon of Christ Church and Principal of Wycliffe Hall, Oxford and his wife, Annis. She named him Gathorne after her brother, Sir Gathorne Hardy, who defeated Gladstone to become MP for Oxford from 1865 to 1876. GRG became an orthopaedic surgeon and a protégé of Sir Robert Jones. In the First World War, the small Wingfield Convalescent Home in Oxford was offered to the War Office, wooden huts were erected there and it became an auxiliary hospital linked to the other units in the Examination Schools and elsewhere, forming the Oxford Orthopaedic Centre, under the care of Girdlestone. After the war, the Wingfield took crippled children, cared for by GRG, and its orthopaedic role widened to embrace the plans of Robert Jones for orthopaedic centres nationwide. It became the Wingfield Orthopaedic Hospital. I have received a foolscap exercise book (Fig. 2) its provenance being by passage through Professor Josep Trueta, the third Nuffield Professor, to his daughter Julie Valderrama and now to me, which proved to be the hand-written minutes of the Wingfield
G
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Fig. 2 The book of minutes Orthopaedic Hospital medical staff committee, composed and signed by GRG, from the start of that committee in 1928 until the arrival of H. J. Seddon as the second Nuffield Professor of Orthopaedics in 1940. The minutes are interesting for the invariable presence of Girdlestone at each meeting and for the gradual introduction by the senior orthopaedic staff of ward and theatre procedures we now take for granted or which have been superceded. The needs for these innovations were often questioned and debated before agreement, as were new instruments that were being introduced. A selection of the matters recorded in the minutes I am unsure who penned the minutes; I think they must have been dictated by GRG and perhaps written out by his wife, Ina, as, for the whole 12 years, they are all in the same handwriting. Comparison with a definite page of GRG’s handwriting, which I hold, excludes him, I think. The minutes were always signed by GRG. The first meeting was on 19th April 1928, attended by GRG, Mr W. B. Foley and Mr G. O. Tippett (Fig.3). I remember ‘Pop’ Foley attending NOC clinical meetings in the 1960s and 70s after he had retired. A subcommittee was formed (Foley & Tippett) to
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Fig. 3 The First Meeting, 19th April, 1928 consider means of standardising the measurements of limb deformities and the range of movements of joints. The second meeting: Thursday 26th April 1928 – GRG, Foley & Tippett. “After considerable discussion” a scheme for measuring and recording 1leg lengths and joint deformities was adopted. Movements were to be recorded as a percentage of normal with angle degrees recorded only if considered helpful. A datum line against which angles might be measured was “Kingsley’s Perpendicular”. I have not found its definition in current medical and general dictionaries and references. After this second meeting the names of the surgeons attending were never recorded. The third meeting: Friday May 11th 1928: suggestion debated – that a blood pressure, pulse and general anaesthesia record form be devised, to be filed in patients’ records. Agreed. The Fourth meeting: recent operative cases were to be discussed at these meetings. From the fifth meeting onwards, operation problems were reported and discussed; for example, the accidental fracture of a femur when manipulating a hip joint, and fatal hypovolaemic shock in a child having spinal fusion. In 1929, “surgical and other errors and disasters” were to be recorded in a special black book “for perusal by the surgical staff only”. Discharge letters: 5th April 1929. “The importance of writing brief reports to the doctor concerned, when his patient was discharged, was emphasised and it was decided that this should be done in future in every case”.. September 1929: Housekeeping and the Feeding of Patients. Agreed that there was room for improvement in several directions; “a higher degree of intelligence and originality in designing menus was ordered and the speed of distributing the food to patients to
render it as palatable as possible was to be sought”. The Hospital Secretary was to discuss this with Matron. Jan 17th 1933: “Definite complaints were laid before the meeting relating to the cooking of food and choice of menu, particularly in D Block (staff accommodation) and the PP Wards. It was stated specifically that meat was often overcooked and served without the usual and proper garnishing, that too much tinned fruit was used and that the sweet courses in general were unattractive & not sufficiently varied. The meeting lent a sympathetic ear to these complaints and it was decided to lay them before an Executive Committee meeting in the near future”. The outcome is not recorded. Finance: The question of sessional payments made to outside anaesthetists was discussed on 30th November 1928. The hospital secretary was instructed to find if there was “any precedent for this”. 30th June 1938 – The hospital secretary’s proposal for introducing personal insurance to cover patients bringing (negligence) actions against the staff was not considered necessary. (oh, happy times!). Staffing: The medical staff committee recommended the appointment as Matron of Sister Knapp as successor to Miss Chesterson on 14th May 1930. The members of the committee subsequently found reasons (not recorded) to reverse this recommendation and, on 25th June 1930, Miss Joliffe’s appointment was recorded. She became a legend – the Nursing School and nurses’ accommodation were named after her. The recruitment and supervision of research staff, nursing and medical teaching, pathologists, radiologists and anaesthetists were subjects discussed over the years. Procedures: Blood pressure recording had been discussed at the second. On 26th October 1928 it was agreed to buy a ‘baumanometer’ for BP measurements. This turns out to be our standard mercury sphygmomanometer; how they measured BPs before is not stated. One sphygmo for the whole hospital! At a later meeting it was decided to take blood pressure readings once or twice post-operatively “in severe cases” and to record these. This followed the case of severe shock in a child after a spinal fusion operation. In September 1929 it was agreed that all surgical cases should have the heart, lungs and blood pressure assessed on the day before operation by the RSO or anaesthetist. At the tenth meeting on 13th September 1928 an operation book to record cases and special problems was to be kept. Techniques were recorded at these meetings. For example, when performing osteotomies, a hand saw was preferable to the chisel or osteotome (30th November 1928). The correct application of dissecting forceps to the skin edge was agreed – two teeth superficially, one deep. Plaster techniques, the duties of the “Aftercare Sisters” and plaster room equipment were considered. On November 11th 1929, it was agreed that a gas & oxygen apparatus was needed for the hospital and the hospital workshop was to construct one. A second N₂O apparatus was to be purchased in 1933.
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BJJ News | I ssue 5 | D ecember 2014
In 1936, the relative costs of gas & air and N₂O were discussed; it was agreed that the anaesthetist’s clinical preference was crucial rather than cost. On 25th November 1930 a portable X-ray apparatus was to be procured by the Hospital Secretary. On 18th December 1929 it was agreed to discontinue weighing patients due to the inaccuracy of the weighing machine. A new one was to be bought. On 28th September 1931 – almost two years later − it was reported that the purchase of a new weighing machine “was definitely in hand”. March 1933: Excessive purchase of drugs and instruments from increasing numbers of firms was to be monitored and subjected to “censorship” by the Clinical Director (GRG). All matters of relevance to the care and welfare of patients, from oral hygiene to the provision of wireless in the wards were debated in committee and recommendations instituted. The 100th meeting of the Staff Committee was held in New College with a dinner and guests. There are photographs in the minutes (Fig.4). Among those present was J.C. Scott whose son, James we know as a recent Editor of our Journal
Fig. 4 10 0th Meeting, New College, 8th December, 1934 Development and reconstruction Staff Meetings regularly discussed plans to replace the old wooden wards (Fig. 5). In the summer of 1930, a knock on the door of his home was answered by Ina, GRG’s wife. A small figure introduced himself as William Morris “of the car factory”. He handed her a cheque for £1 000 (now about £28 000) to repair the hospital buildings. In November 1930, Morris (later Viscount Nuffield) offered enough to rebuild the entire hospital, £76 000 in all – equivalent in effect to £4.5 million. From these benefactions emerged the Wingfield-Morris Orthopaedic Hospital (Fig. 6) and, with its completion and the donor’s peerage, the Nuffield Orthopaedic Centre. Preparation for War The imminent war was first noted on 13th March 1939 – discussion on the organisation of the hospital to receive civilian casualties – inpatients were to be moved out to make room. Five mobile orthopaedic units were to be organised and deployed to places where casualty numbers were heavy. Air raid practices for casualty reception were planned. They needed 40 stretcher bearers, sorting rooms for casualties and supplies for blood transfusion.
Fig. 5 The wooden huts of the Wingf ield before rebuilding
Fig. 6 The wards af ter Lord Nuff ield’s gif ts and the rebuilding in the 1930s The Nuffield Professor of Orthopaedics The first Nuffield Professor of Orthopaedics was GRG. He took office in 1937 and resigned in 1940. Surprisingly, there is no record in these minutes of the appointment by the university of GRG to the professorship or when he assumed that mantle; an example of his modesty perhaps. In 1940 H. J. Seddon was appointed the second Professor. There is no record in these minutes of the appointment of Seddon to our Nuffield professorship. He stayed till 1948 when he moved to the RNOH. The WMOH staff committee minutes were signed by GRG till 27th November 1939. Seddon first signed on the 15th January 1940. The last written entry in these minutes was for the staff meeting on 8th April 1940. It was not subsequently signed. I do not know if Professor Seddon kept any minutes after the end of these records on 8th April 1940 – perhaps they were typed and filed elsewhere. It was minuted in February 1940 that he had ordered a Dictaphone!
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details
Barry Fearn Former Girdlestone Orthopaedic Society Archivist, Hayward’s Heath, England fearnfamily@hotmail.com
14
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Orthopod’s view
F. Monsell
Jan van Eyck and the Northern Renaissance; a personal appreciation
I
was the product of ver y
London, where I was initially living alone while
conventional, one-dimensional
attempting to repatriate the rest of my family.
schooling, the central tenets of
The summer was very hot, I was at a loose end
which appeared to be: to learn
in the evenings and I found a building in central
science, but not necessarily understand it; to
London that was open late on Wednesdays. It was
write it down in silence, always remembering to
equipped with excellent air conditioning and I
have a selection of pens and sharp pencils; to
retreated there to read my copy of Viz.
score as many marks as possible and then go to university and do it all over again.
I noticed that there was a bewildering collection of pictures of fields, elderly gentlemen and large ladies with their bosoms on display and later learned that the building was known as the National Gallery. A few of the exhibits were much more interesting
Fig. 3 The Annunciation Diptych circa 1433-1435
and I found that I would return to them to have a
The National Gallery was founded in 1824, from
closer look. This began a hobby that has persisted
an initial purchase of 36 paintings and has grown
and evolved into a reasonably sophisticated
to about 2300 paintings by 750 artists dating from
appreciation of what is generally referred to as
the mid-13th century to 1900.
Fine Art.
It is also a five-minute walk from the offices of the Bone and Joint Journal and this has allowed me
Fergal Monsell describes how he developed a hobby alongside professional commitments and travels.
to combine editorial duties with my secret hobby. I still walk past the fields, the elderly gentlemen and the large ladies and come to rest on the art of the Northern Renaissance. This refers to the work of artists, sometimes known as the Flemish Primitives, who were active in Burgundy and the Habsburg Netherlands, starting with Robert Campin and Jan van Eyck in the early 1420s.
Fig. 1 The Arnolf ini por trait circa 1390 –1441
Their work followed the International Gothic style and lasted at least until the death of Gerard
I do not recall a classical component and,
David in 1523. The origin of this style coincided
as a younger man, I was firmly convinced that
with the Early Italian Renaissance but developed
all poetry should rhyme, music should always
as a separate entity with dif ferent terms of
involve the electric guitar and art was for girls.
reference and a visibly different style.
During my evolution into an or thopedic
The major exponents include Rogier van der
surgeon, I felt comfortable that I was largely
Weyden, Dieric Bouts, Petrus Christus, Hans
amongst kindred spirits and that this mindset
Memling, Hugo van der Goes and Hieronymus
was conventional and widely held.
Bosch. These artists generally used oil on oak
There were notable exceptions and while it was
panel, to produce single works or more complex
entirely satisfactory to have excelled at sport, an
portable or fixed altarpieces in the form of
association with the arts was generally considered
diptychs, triptychs or polyptychs.
to be a little odd.
They made significant advances in the
I began my consultant career in 1997: this was an interesting time of my life from many perspectives. It was the year that I moved to
understanding and representation of perspective
Fig. 2 The Man in a Red Turban circa 1433
and their works typically feature complex Catholic iconography. I look at their paintings from a
15
BJJ News | I ssue 5 | D ecember 2014
purely secular perspective and have come to
(The Adoration of the Mystic Lamb, Fig. 6) to
consider the subjects as old friends who I see
address the Belgian Orthopaedic Association.
from time to time and about whom I learn a
This essay is in part a confession to explain
little bit more each time we meet.
my willingness to travel under the guise of
Although, to my mind van der Weyden is
orthopaedic education when there has long
more technically proficient, Jan van Eyck is more
been a personal hidden agenda, to explore the
interesting and gets my vote. The National
world of the Flemish primitives in general and
Gallery has an important collection of his work
the art of van Eyck in particular. The painting
and while the Arnolfini portrait (Fig. 1) is better
that I hold most dear is the Crucifixion and
known, The Man in a Red Turban (Fig. 2) is a
Last Judgement diptych (Fig. 7) in the New
more compelling example of this man’s unique
York Metropolitan Museum (NF Consortium
skills.
meeting) which, when I close my eyes, I can
Jan van Eyck was born between 1380 and 1390,
see in considerable detail.
most likely in Maaseik in the Meuse valley.
D u r i n g o n e r e u n i o n , I wa s c l o s e l y
Very little is known of his early life but he had
scrutinised after arriving shortly before closing
two brothers who were also artists and some
time and looking intently at this work for at
of his work, particularly the Adoration of the
least 45 minutes.
Mystic Lamb, was executed in collaboration
On reflect ion, I was possibly a little
with Hubert.
underdressed even by my own rudimentary
Van Eyck was employed as painter by John of
sar torial standards and became aware of
Bavaria-Straubing, ruler of Holland around 1422.
something of a commotion in my peripheral
After John’s death in 1425, he was employed
vision.
as court painter to Philip the Good, Duke of
There were muted whispers and the arrival
Burgundy, where he remained until 1429, after
of men in uniform before I was challenged by
which he moved to Bruges, working for Philip
a man in curator’s costume about my apparent
until his death there in 1441.
interest in the exhibit.
I have arranged my professional life to allow
I responded with a potted history of the
me to seek out the best examples of his work
work, a personal opinion on the comparative
and have often accepted invitations on the basis
merits of van Eyck and van der Weyden, why I
of the proximity to a van Eyck masterpiece.
thought that Michelangelo had never actually
I have visited Madrid (The Annunciation, Fig. 4) to operate, Berlin (The Madonna in the
Fig. 5 Madonna of Chancellor Rolin circa 1435
seen a mature female breast and why da Vinci couldn’t do hands.
Church, Fig. 5) to contribute to an international
I was allowed to remain for an hour after
Ilizarov symposium, Paris (The Madonna of
closing time and we all parted friends. At least
Chancellor Rolin) to attend an EFORT Forum
I think we did, but I got the feeling that the
and Ghent
curator was more than a little relieved that the
Fig. 6 Adoration of the Mystic Lamb ( The Ghent Altarpiece) circa 1430/1432
painting was still on display the following day. This is a continuing journey: I will be visiting Orlando in January to attend a course on hip reconstruction in Proximal Focal Femoral Deficiency. I intend fly into Washington DC (The Annunciation) and home from New York (The Crucifixion) to feed my hobby. Whether or not this is considered by others to be a legitimate way to abuse study time, it has certainly worked for me.
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16
Fig. 4 Madonna in the Church circa 1438/1490
details
Fergal Monsell MSc, PhD, FRCS(Orth) Consultant Orthopaedic Surgeon, Royal Hospital for Children, Bristol fergal.monsell@ubht.swest.uk
Fig. 7 The Crucif ixion and Last Judgement Circa 1435/1440
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Orthopod’s profile
Dr San Baw; The man behind ivory hemiarthroplasty
B. Szostakowski J.A Skinner
Bartek Szostakowski and John A Skinner pay tribute to a little-known pioneer of hip arthroplasty he concept of joint replacement was originally proposed and introduced by Themistocles Gluck. In 1890 he implanted a hinged ivory knee joint into a 17- year-old girl. Although he reported that he performed 14 arthroplasties that year, including a hip, he only provided details on five; three knees, a wrist and an elbow.1 For most orthopaedic surgeons worldwide, even specialists in hip arthroplasty, Dr San Baw’s name and story are unfamiliar. However, during his lifetime, for many people in Burma he was considered a hero and life saver and received many prizes and honours. He was born on 29th June 1922 and this year, the 7th December marks the 30th anniversary of his death. His story has hitherto never been commemorated by any article in an international orthopaedic journal. Dr San Baw graduated with a Bachelor of Medicine and Bachelor of Surgery from Rangoon University Medical School in March 1950. Between 1954 and 1957 he studied for his MA in Orthopaedics at the University of Pennsylvania’s Graduate School of Medicine under Paul C. Colonna and J.T Nicholson defending his thesis on “A Radiographic and Microscopic Correlative Study of Avascular Necrosis in the Femoral Head in Dogs”. While in the US he conceived his idea of ivory as a perfect material for hip replacement in fractures of a neck of femur. Only few years earlier hemiarthroplasty for fractured neck of femur was popularised by two American orthopaedic surgeons, Fred Thompson and Austin T Moore, who independently introduced implants made of Vitallium, an alloy of cobalt and chromium.2 In 1950 Thompson developed a prosthesis with a distinctive flared collar below the head and a vertical intramedullary stem. Austin Moore’s prosthesis in 1952 featured a fenestrated stem to allow bone ingrowth.2 Upon return to Burma in 1958 at the age of 36 he was appointed Head of the Department of Orthopaedic Surgery at the General Hospital in Mandalay,3 the second largest city in Burma. For almost a year after his arrival he conducted research on the physical and chemical properties of ivory, as well as its potential merits and capacity to withstand strain and stress before he decided to perform his first operation. At that time ivory was still cheap and readily available in Burma, whereas the cost of a Vitallium hemiarthroplasty was beyond the reach of a Burmese orthopaedic surgeon in the 1960s. At that time there were about 2000 elephants in captivity. There was no question of animals being slaughtered for their tusks. Elephants were leading useful lives in Burma and were used extensively for carrying and hauling timber. Ivory was harvested only from elephants that died naturally, after which their tusks were sold to the public. During his research and tests on ivory he found a craftsman who specialized in ivory carving. He took with him a wooden model of a
T
Fig. 1a U Tin Aung Ivor y carver with template Photo by Dan Stiles hip joint in order to explain what he wanted. In the beginning it was very difficult for a sculptors to understand the idea of a hip replacement. Sculptors assigned to carve prostheses from ivory sometimes found the work distasteful and difficult to understand because they were accustomed to fashioning ivory into works of art, unlike hip replacements which were not to be admired aesthetically (Fig.1). During work on design and manufacture of the replacement, he had to think about biomechanics, as the Burmese almost never use a commode but rather squat fully for toilet purposes. Finally, in 1960 after almost a year of various tests and detailed research, for the first time he used his ivory prosthesis to replace the fractured hip of an 83-year-old Burmese Buddhist nun, Daw Punnya.
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BJJ News | I ssue 5 | D ecember 2014
Fig. 1b Finished prostheses Photo by Dan Stiles Within two weeks post-operatively she was able to move without any problems. Encouraged by the results of his early replacements, he realised that his ivory project would become popular and require careful surveillance and further research. Patients required regular follow-up and interval radiographs and Dr San Baw reached a stage when he could no longer afford to support the cost of ivory, carving and travel expenses for his patients from his savings. In 1965 government of Burma supported his research expenses which made things much easier and allowed his research to progress towards the final phase of manufacturing a most effective ivory prosthesis Between 1960 and 1969, more than 100 patients aged from 24 to 87 were fitted with an ivory replacement.³ Only a few of them reported in direct complications such as fracture of the replacement which was usually a result of a fall from the patient’s own height. He used this replacement not only for fractured femoral necks but also for other pathologies like ankylosed hip joints. The total cost of an ivory prosthesis manufactured at that time in Burma was around 100 kyats (£10), compared with 200 kyats for a Thompson replacement.3
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In 1969, he was invited to the British Orthopaedic Association (BOA) meeting at the Royal College of Surgeons in London, where he presented results of his work entitled “Ivory prosthesis for ununited fractures of the neck of femur” (Fig.2). He described the use of a hemiarthroplasty made of ivory which on static compression testing was similar to Vitallium and titanium.4 The meeting was held under the Presidency of Professor Roland Barnes who was a member of the MRC team which produced a definitive review of the surgical treatment for fractures for the neck of femur.5 The ivory replacements had a weak shear strength when tested parallel to the grain, which had to be taken into account in their manufacture. The coefficient of friction of polished ivory on cartilage was 0.04, a value close to that of a normal joint (0.02). The implant was shaped like a Thomson prosthesis. A number of the early models fractured at the neck of the prosthesis, but modifications to produce a thicker collar with reduced curvature between the neck and stem prevented this complication (Fig. 3). By the time he read his paper to the BOA in 1969, he had used the prostheses in 100 cases of ununited fracture of the femoral neck during the past ten years and no adverse reaction to the ivory had been seen. 88% of the cases had a good or excellent result, based on Judet’s criteria. In his country it was important to be able to squat, and 76% of his patients had regained this ability. The majority were not only able to walk and squat but also played football and cycle. The complications included breakage of the stem in seven cases, five of which had been replaced. Three had dislocated post-operatively but were reduced with good outcomes. The cancellous bone of the femoral shaft formed a strong bond with the ivory stem, which underwent marginal erosion with invasion by bone, thereby producing a very strong biological bond described as creeping substitution. Dr San Baw presented an ivory prosthesis which the President accepted on behalf of the Association.6
Fig. 2
Dr San Baw with par ticipant , British Or thopaedic Association Meeting. London 1969 (For ward Magazine, Rangoon, Burma , November 15th, 1969).
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Fig. 3 Various prostheses. Note thickened collar on lef t . Photo by Myint Zan
Upon his return to Burma Dr San Baw continued with his ivory replacements until his retirement in 1980. From January to June 1976 he visited hospitals in Malaysia, Singapore, Hong Kong and Australia on a World Health Organization fellowship where, among others, he lectured on the use of ivory prostheses. In Australia he visited Sydney, Melbourne, Adelaide, Brisbane, and Perth became known as ‘the ivory prince’. At the University of Malaya Hospital in Kuala Lumpur, he performed a few operations on congenital pseudarthrosis of the tibia with his new technique which became eponymous. At the beginning of the 1990s, due to restrictions on use of the ivory, only in exceptional cases and with special permission, could ivory be used for hip replacements. It is estimated that a total of more than 300 ivory hemiarthroplasties were implanted between 1960 and 1980 Dr San Baw also conducted research on the use of ivory powder as a bone substitute to fill cavities after removal of various bone cysts and tumours and developed transarticular grafts for infantile pseudoarthrosis of the tibia.7 Because his presentation on ivory hip prostheses was published only as an abstract in the Journal of Bone and Joint Surgery (British volume) and his paper on pseudarthrosis was published as a full article, it appears that some orthopaedic surgeons were more aware of Dr San Baw‘s work with infantile pseudarthrosis than ivory prostheses. His technique of treating infantile pseudarthrosis of the tibia is included in Campbell’s Operative Orthopaedics but not his pioneering work with ivory prostheses.
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B. Szostakowski , Resident in Trauma and Orthopaedics Department of Trauma and Orthopaedics
The Infant Jesus Hospital, 4, Lindleya Str., 02-005 Warsaw, Poland bartek.szostakowski@gmail.com
Dr San Baw died on the 7th of December 1984 of a metastatic brain tumour following chemotherapy for lung cancer He was survived by his wife Dr Myint Myint Khin (1923 to 2014), retired Professor of Medicine at the Institute of Medicine, Mandalay (an obituary of Dr Myit Myint Khin, written by Ned Stafford ‘Legendary Burmese Doctor and Teacher and Later a Poet’ is published in the British Medical Journal, 2014;349:g5397), and a son Dr. Myint Zan, Professor, Faculty of Law, Multimedia University, Malacca, Malaysia. In 1985, Dr. Myint Myint Khin established a ‘Dr San Baw Prize’ for medical research by Burmese medical doctors and only two prizes to date have been awarded. One was awarded in 1989 to Dr Phyu Phyu Aung et al at for their paper ‘Physiological effects of Tobacco Dust Exposure in the Cigarette Factories of Rangoon’ and another in 1995 to Dr. San San Myint et al for their paper on ‘ Task Analysis of Midwives’. As the Chair and members of the Dr San Baw prize committee felt there was no paper of sufficient merit since 1996, the funds were diverted to collate and index Master of Medical Science theses submitted but again due to the difficulty in tracing them only those submitted up to 1990 were able to be collected and collated. Later, part of the funds were used to defray the expenses of Burmese orthopaedic surgeons who studied abroad, to which Dr. Myint Zan, son of Dr San Baw, also contributed personally We do not know how many Burmese with ivory prostheses are still alive. As of 1969, the youngest of Dr San Baw’s patients was aged 24 when the hip replacement was done and since Dr San Baw undertook ivory hip replacements until about 1980 we estimate there could be up to a dozen or even more Burmese alive with ivory hip prostheses. On the 30th anniversary of Dr. San Baw’s death we are pleased to offer this tribute to commemorate his pioneering work.
Acknowledgements:The authors wish to thank Professor Myint Zan who answered numerous questions about his late father and delivered necessary information without which this article would not be possible References 1. Brand RA, Mont MA, Manring MM. Biographical Sketch Themistocles Gluck (1853–1942) Clin Orthop Relat Res 2011;469:1525–1527. 2. Gomez PF, Morcuende JA. “Early attempts at hip arthroplasty—1700s to 1950s”. Iowa Orthop J 2005;25: 25–29. 3. No authors listed. Use of ivory in replacement prosthesis discovered. The Working People’s Daily, Rangoon Wednesday, September 17, 1969. 4. No authors listed. Proceedings and Reports of Universities Colleges, Councils and Associations J Bone Joint Surg [Br]1970;52-B. 5. No authors listed. Obituary Roland Barnes 1907 – 1998. J Bone Joint [Br] 1999;81B. 6. No authors listed. Surgeons hear U San Baw’s ivory prostheses in London. The Working People’s Daily, Rangoon, Thursday October 16, 1969 7. San Baw U. The transarticular graft for infantile pseudoarthrosis of the tibia. A new technique. J Bone Joint Surg [Br]1975;57-B.
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J. A. Skinner, FRCS(Eng),FRCS(Orth), Consultant Orthopaedic Surgeon President British Hip Society
Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
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BJJ News | I ssue 5 | D ecember 2014
Current practice
Sporting injuries of the foot and ankle ateral ligaments of the ankle One of the most common injuries of the lower limb is a sprain of the ankle, most of which occur in people under the age of 35 years.1 They are commonly seen after dancing, ballet, running, football, and basketball.2-4 In two-thirds of cases it is usually the anterior talofibular ligament (ATFL) that is damaged.5 Delayed physical examination (usually four to five days after the initial injury) remains the gold standard in the diagnosis of an acute injury.6-8 Pain over the ATFL strongly suggests an acute injury. A positive anterior drawer test of the ankle has 73% sensitivity and 97% specificity for ATFL injury.6-8 Ultrasonography and MRI are useful in diagnosis. The former allows quick diagnosis but is operator dependant, with a sensitivity of 92%, specificity of 64% and positive and negative predictive values of 85% and 77% respectively. 6, 8 MRI is also reliable and can show other injuries such as osteochondral lesions. Functional treatment using laceup or semi-rigid braces or tape gives better outcomes in relief of symptoms and return to work and sport than immobilisation.9 After non-operative management, 20% of patients will continue with symptoms of instability.10 Surgery is reserved for cases which failed to respond to non-operative measures. BrostomGould repair remains the gold standard for primary repair of the injured lateral ligament: its failure rate is approximately 5%. An arthroscopically-assisted Brostrom-Gould repair has also been described with promising results. When recurrent instability occurs after a Brostom-Gould repair, reconstruction using a tendon graft may be considered. The choice of graft is the surgeons preference and varies between autologous hamstring grafts using semitendinosus or gracilis and plantaris. The AFTL is reconstructed in all cases and the calcaneofibular ligament (CFL) is usually reconstructed at the same time.
L
Syndesmosis The syndesmosis complex comprises the anterior inferior tibiofibular ligament
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M. Ballal J. Calder
Moez S. Ballal & James D.F Calder take us through modern thinking on injuries to this vulnerable joint (AiTFL), the posterior inferior tibiofibular ligament (PiTFL), the interosseous ligament (IOL) and the transverse tibiofibular ligament (TTL). The incidence of syndesmosis injuries ranges between 1% and 18% of ankle sprains.11, 12 The injury usually occurs as a result of external rotation of the foot and ankle with the foot in pronation and ankle in dorsiflexion.1314 Pain located over the anterolateral aspect of the ankle on passive dorsiflexion may suggest an injury to the syndesmosis. The squeeze test and the external rotation test are not sensitive but are highly specific for syndesmosis injury if positive. The West Point grading system divided syndesmotic injuries into three grades based on clinical examination.15 Grade I is a mild sprain to the AiTFL with no clinical instability; Grade II includes tears of the AiTFL and a complete tear of the IOL with slight instability, while Grade III implies complete disruption of all ligaments and definite instability. Weight-bearing AP, mortise and lateral radiographs of the ankle can help establish the diagnosis. Findings such as increased clear space between the talus and medial malleolus and increased tibiofibular clear space of more than 6 mm at a point 1 cm above the tibial plafond are highly suggestive of injury. MRI scans show a 100% sensitivity and 93% specificity for AiTFL and a 100% sensitivity and specificity for PiTFL injuries.16 Arthroscopy can also play a role in diagnosis and be therapeutic when there are associated injuries such as osteochondral lesions. Non-operative treatment for Grade I stable syndesmotic injuries gives good results. Immediate rest, ice and immobilisation in a boot or non-weight-bearing cast for five to seven days helps to lessen swelling and reduces the initial period of inflammation. This is followed by 7 to 14 days of partial weightbearing accompanied by physiotherapy which concentrates on proprioception and range of
movement exercises. Full weight-bearing with strength straining is then started. The ability to single leg hop for 30 seconds is a good sign of healing and is usually seen after six to eight weeks. Arthroscopy can be a useful to diagnose and address instability in cases of grade II injury. In the recreational sportsperson, it can be treated non-operatively with good results but with a prolonged period before returning to sports. Examination of the ankle under anaesthesia and arthroscopy is recommended for the professional athlete with dynamic instability and a grade II injury. Surgical fixation is warranted in the presence of a dynamic diastasis of 2mm or more. Grade III injuries are best dealt with by arthroscopy before fixation to address associated articular damage. Surgical repair can be undertaken using different methods: these include screw fixation, suture button ‘tight rope’ technique or direct repair of the AiTFL. When using screw fixation, there appears to be no difference if three or four cortices are fixed. There is no clinical difference in the range of movement of the ankle if the screws are tightened with the ankle in dorsiflexion or plantarflexion. 17 A recent radiological study which compared screw fixation with TightRope fixation for reduction of the syndesmosis showed that the TightRope technique was more accurate.18 If the syndesmosis is grossly unstable, two screws or two tightropes may be used successfully. Post-operatively, immobilisation in a non weight-bearing cast or boot for 10 to 14 days will help the wounds to heal. Partial weight-bearing and proprioception exercises are started after 3 to 4 weeks, followed by full weight-bearing with return to full sporting activities at eight weeks. Kennedy et al 19 showed that patients with a grade III injury returned to sports three weeks earlier when treated operatively than in a cast.
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Chronic syndesmosis injury Missed syndesmosis injuries may result in chronic instability and the early onset of osteoarthritis if associated with lateral shift of the talus. The diagnosis is usually based on clinical examination and imaging. Most studies have recommended using MRI to identify associated intra-articular injury. Many agree that arthroscopy should be undertaken to debride the soft tissues which form anterior and distal to the AiTFL as well as to clear the medial gutter in cases where there is an associated deltoid ligament injury. Once reduction has been achieved, fixation is similar to that of the acute injury. Any associated injury to the lateral structures of the ankle which have been missed should also be addressed. Rehabilitation is the same as for the acute injury. Deltoid ligament The deltoid ligament limits pronation, abduction and external rotation of the talus. It consists of two parts, superficial and deep. When the deep deltoid ligament and ATFL ligament are sectioned, external and internal rotation movements of the talus are increased. When the syndesmosis is also sectioned the talus becomes very unstable and will dislocate on external rotation. Isolated injury to the superficial part of the deltoid ligament is a stable injury with a good prognosis. Injury to both parts of the deltoid is usually associated with other ankle injuries. Pain and swelling over the medial side can indicate injury but testing instability in the acute setting may be difficult. Once the acute phase has subsided, delayed examination may be helpful. Useful tests are the gravity stress test, anterior drawer test with the foot in external rotation and the lateral tilt test. Stress radiographs comparing the injured with the uninjured foot may identify medial opening.With a chronic injury to the deltoid ligament, patients may present with instability and a high hindfoot valgus deformity. It is always important to assess the lateral structures to rule out associated injuries. MRI scanning is useful to detect chondral injury. Isolated superficial or partial tears are treated in a non-weight-bearing boot for five to seven days and rehabilitation is started at the same time. Patients usually return to full weight-bearing after six to eight weeks and light training. In the cases of complete tears of both parts of the deltoid ligament, arthroscopy is undertaken to identify and deal with any intra-articular pathology. Lateral ligament and syndesmosis injuries are dealt with at the same time. Repairing the deltoid is carried out before fixing the lateral ligament structures. We believe that early stabilisation in the athlete may help in early rehabilitation and return to sports, although there is no high-level evidence to support this.
Lisfranc injuries The Lisfranc or tarsometatarsal joint complex is the foundation of the transverse and longitudinal arches of the foot. The second tarsometatarsal joint forms the keystone of the arch as it is wedged between the medial and the lateral cuneiforms. The joint capsule of the tarsometatarsal joint is divided into three parts; the medial, which supports the first tarsometatarsal joint; the middle, which supports the second and third tarsometatarsal joints and the lateral, which supports the fourth and fifth tarsometatarsal joints. Interosseous ligaments join the bases of the second to the fifth metatarsals and the Lisfranc ligament joins the medial cuneiform to the base of the second metatarsal bone. It is the strongest and largest of the interosseous ligaments. The dorsal and plantar ligaments also help to support the joint complex. Most injuries to the Lisfranc joint occur as a result of a twisting or axial force to the plantarflexed foot although it may also be injured by crushing. The ligament can be injured in isolation in cases of a mild Lisfranc ligament sprain, in association with a fracture-dislocation of the Lisfranc complex or in combination with other fractures such as a crush fracture of the cuboid, the so-called ‘nutcracker injury’. Due to the proximity of the deep peroneal nerve and dorsalis pedis artery to the Lisfranc joint, compartment syndrome may occur as a result of the injury as well as damage to the deep peroneal nerve: these injuries should be identified at the time of clinical examination. A high index of suspicion is needed when diagnosing Lisfranc injuries: the rate of missed injuries can be as high as 20%. 20 A plantar ecchymosis raises the suspicion of such injury. Standard non-weightbearing radiographs of the foot (three views) are the first-line investigation when imaging for an acute Lisfranc injury. A diastasis of more than 2 mm between the medial cuneiform and the second metatarsal base indicates a Lisfranc ligament injury and instability. The presence of a fleck sign can also been seen radiologically and this is pathognomonic. When non-weightbearing radiographs are normal, then three weight-bearing of the foot can identify diastasis of the Lisfranc joint. CT scans can also help detail underlying fracture patterns. MRI scans can identify subtle Lisfranc sprains that cannot be seen on plain radiographs. Injuries which are not grossly unstable can initially be immobilised in a cast or boot without further immediate action. The disruption may be incomplete or complete. With incomplete ligamentous disruption, there
are three stages: stage 1, with less than 2 mm diastasis and no arch collapse; stage 2, with 2mm to 5mm diastasis and no arch collapse and stage 3, more than 5 mm diastasis as well as medial arch collapse. With complete disruption, this can be with or without significant intra-articular fracture. For stable stage 1 injuries, good results have been reported, even in athletes, with nonoperative treatment using immobilisation in a cast or boot non-weight bearing for six weeks. In unstable stage 1 and stage 2 and 3 injuries, nonoperative management has been associated with a poor outcome. 22-24 Definitive fixation aims to reduce the disrupted joints anatomically. This can be achieved either by open reduction and internal fixation with screws and wires, or by using plates. In non-displaced or mildly displaced injuries, closed reduction and percutaneous fixation has also given good results. The incidence of post-traumatic midfoot arthritis is high and some authors advise primary fusion for such injuries. A prospective randomised trial which compared primary fusion and open reduction and internal fixation for Lisfranc injuries concluded that primary fusion resulted in a significant reduction in the rate of hardware removal with no significant difference in functional outcome. 25 First metatarso-phanangeal joint plantar plate The plantar plate is a thickened plantar capsule which originates under the metatarsal head at the distal aspect of the sesamoids and courses distally to become attached to the plantar aspect of the base of the proximal phalanx of the big toe. It helps to stabilise the 1st metatarso-phalangeal joint (MTPJ) along with other structures such as the collateral ligaments and the tendons of flexor hallucis longus and brevis. It prevents hyperdorsiflexion of the 1st MTPJ. Injury to the plantar plate of the big toe occurs when an axial load is applied to the plantarflexed foot with the big toe in extension at the 1st MTPJ. The injury can be classified into three grades; Grade 1: mild sprain, Grade 2: a partial tear with some restriction of movement of the 1st MTPJ, and Grade 3: a complete tear with instability of the 1st MTPJ.26 Clinical examination may identify swelling and pain at the level of the 1st MTPJ. Instability can be assessed using the dorsal-plantar drawer test. Imaging includes weight-bearing AP radiographs of the both feet: these will show sesamoid retraction proximally on the injured side when compared with the normal side. A lateral view of the 1st MTPJ with dorsiflexion of the big toe will also show
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BJJ News | I ssue 5 | D ecember 2014
an increased gap between the sesamoid and base of the proximal phalanx. MRI scanning can identify subtle injuries and those which cannot be detected on plain radiographs. With a grade 1 injury, the athlete can usually return to competition as pain allows. Taping of the big toe in slight plantarflexion may help to limit movement as the plantar plate heals. A carbon-fibre turf toe orthotic plate can help limit movement of the toe. Range of movement exercises are started between three and five days. For Grade 2 injuries, a walking boot with crutches for up to two weeks may be needed. Grade 3 injuries may need eight weeks immobilisation. The big toe should allow 50º to 60° of pain-free movement before the patient returns to full activities. Surgery is indicated if there is retraction of the sesamoid, a traumatic hallux valgus deformity, vertical instability of the 1st MTPJ, loose bodies or a chondral lesion of the 1st MTPJ, or after failed conservative treatment.27 In cases of complete rupture, a two-incision approach (medial and plantar) allows better access to both sides of the plantar plate. Post-operatively, the foot should be nonweight-bearing for four weeks in a toe spica. Passive range of movement exercises are started at one week to reduce stiffness. Protected weight-bearing in a boot is started at four weeks followed by a stiff orthotic at eight weeks.
4. Lindenfeld TN, Schmitt DJ, Hendy MP et al.
16. Takao M, Ochi M, Oae K. Diagnosis of a
Incidence of injury in indoor soccer. Am J Sports Med
tear of the distal tibiofibular syndesmosis. The role
1994;22:364–371.
of arthroscopy of the ankle. J Bone Joint Surg [Br]
5. Brostrom L. Sprained ankles. V. Treatment and
2003;85-B:324–329.
prognosis in recent ligament ruptures. Acta Chir Scand
17. Tornetta P III, Spoo JE, Reynolds FA
1966;132:537–550.
et al. Overtightening of the ankle syndesmosis:
6. Van Dijk CN. On diagnostic strategies in patients
is it really possible? J Bone Joint Surg [Am]
with severe ankle sprain. Thesis, University of
2001;83-A:489–492.
Amsterdam, The Netherlands 1994 (ISBN: 9090068805/
18. Naqvi GA, Cunningham P, Lynch B, Galvin
ISBN).
R, Awan N. Fixation of Ankle Syndesmotic Injuries
7. Van Dijk CN, Lim LS, Bossuyt PM, Marti RK.
Comparison of TightRope Fixation and Syndesmotic
Physical examination is sufficient for the diagnosis of
Screw Fixation for Accuracy of Syndesmotic
sprained ankles. J Bone Joint Surg [Br] 1996;78:958–962.
Reduction. Am J Sports Med 2012; 40: 2828-2835.
8. Van Dijk CN, Mol BW, Lim LS, Marti RK,
19. Kennedy JG. Surgical vs non-surgical
Bossuyt PM. Diagnosis of ligament rupture of
treatment of syndesmotic injuries. J Orthop Trauma
the ankle joint. Physical examination, arthrography,
1990;14:232–240.
stress radiography and sonography compared in 160
20. Trevino SG, Kodros S. Controversies in
patients after inversion trauma. Acta Orthop Scand
tarsometatarsal injuries. Orthop Clin North [Am]
1996;67:566–570.
1995;26:229-238.
9. Kerkhoffs GM, Rowe BH, Assendeift WJ et al.
21. Meyer SA, Callaghan JJ, Albright JP, Crowley
Immobilisation and functional treatment for acute
ET, Powell JW. Midfoot sprains in collegiate football
lateral ankle ligament injuries in adults. Cochrane
players. Am J Sports Med 1994;22:392–401.
Database Syst Rev 2002;3:CD003762.
22. Nunley JA, Vertullo CJ. Classification,
10. Freeman MAR. Instability of the foot after injuries
investigation, and management of midfoot sprains:
to the lateral ligament of the ankle. J Bone Joint Surg [Br]
lisfranc injuries in the athlete. Am J Sports Med
1965;47-B:669–77.
2002;30:871–878.
11. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler
23 Shapiro MS, Wascher DC, Finerman GA.
JH. Syndesmosis sprains of the ankle. Foot Ankle
Rupture of Lisfranc’s ligament in athletes. Am J Sports
1990;10:325–330.
Med 1994;22:687–691.
12. Jones MH, Amendola A. Syndesmosis sprains of
24. Henning JA, Jones CB, Sietsema DL, Bohay
the ankle: a systematic review. Clin Orthop Relat Res
DR, Anderson JG. Open Reduction Internal
2007; 455:173–175.
Fixation versus Primary Arthrodesis for Lisfranc
References
13. Fritschy D. An unusual ankle injury in top skiers.
Injuries: A Prospective Randomized Study. Foot Ankle
1. Nilsson S. Sprains of the lateral ankle ligaments II.
Am J Sports Med 1989;17:282–286.
Int 2009;30: 913-922.
Epidemiological and clinical study with special reference
14. Xenos JS, Hopkinson WJ, Mulligan ME,
25.
to different forms of conservative treatment. J Oslo City
Olson EJ, Popovic NA. The tibiofibular syndesmosis:
disorders. In: Porter DA, Schon LC, eds. Baxter’s
Hosp 1983;33:13–36.
evaluation of the ligamentous structures, methods of
The Foot and Ankle in Sport. 2nd ed. Philadelphia, PA:
2. Balduini FC, Vegso JJ, Torg JS et al. Management
fixation, and radiographic assessment. J Bone Joint Surg
Elsevier Health Sciences; 2007:411-433.
and rehabilitation of ligamentous injuries to the ankle.
[Am] 1995; 77-A:847–856.
26 McCormick JJ, Anderson RB. The great toe:
Sports Med 1987;4:364–380.
15. Gerber JP, Williams GN, Scoville CR, Arciero
failed turf toe, chronic turf toe, and complicated
3. Colville MR. Surgical treatment of the unstable
RA, Taylor DC. Persistent disability associated with
sesamoids injuries. Foot Ankle Clin 2009;14:135-150.
ankle. J Am Acad Orthop Surg 1998;6:368–377.
ankle sprains: a prospective examination of an athletic population. Foot Ankle 1998;19:653–660.
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details
M. S Ballal Foot and Ankle Fellow, Fortius Clinic and Chelsea and Westminster NHS Trust J. D. F Calder Consultant Orthopaedic Surgeon, Fortius Clinic and Chelsea and Westminster NHS Trust. j.calder@ic.ac.uk
Anderson RB, Shawen SB. Great-toe
BJJ News
BJJ News | I ssue 5 | DECEMBER 2014
Letters
The 2104 Vicary Lecture A unique occassion for orthopaedic surgery
“
Sir, Far be it from me to blow my own trumpet but I thought I should report
a unique coincidence surrounding the 2014 Thomas Vicary Lecture and Dinner at The Royal College of Surgeons of England on 9th
We want your views!
October. I had the honour of being the 92nd Lecturer, and the event endorses the enduring friendship between the College and The
E- m ai l : b j j n ews@b o n ean d j o i n t. o rg.uk
Worshipful Company of Barbers, a relationship which dates from 1540, when King Henry VIII granted a Charter which joined the Company of Surgeons with the Barbers. It is not necessary for the Barbers to be medically qualified and
The title of my talk was ‘The search for Shenton’s
References
line’. In this, I described an outstanding man of his
1. Shenton EWH. A diagnostic line about the hip joint.
The Vicary Lecturer is required to present on a topic
time and uncovered four references1¯4 to his ‘line’
Journal of Physical Therapeutics 1902;3:110-112.
related to the history of surgery and over the years
which hitherto has been quoted unreferenced in
2. Shenton EWH. A system of radiography. Archives of the
the lecturers have come from all branches of surgery,
the written and spoken word by the orthopaedic
Roentgen ray 1901-2; 6:62-70.
with orthopaedic surgeons in a small minority.
community at large. Of the four references, I prefer
3. Shenton EWH. Disease in Bone Pub. McMillan and
the first as this was the occasion when Shenton
Co;1911: 42.
indeed they come from many professions.
The coincidence I wish to report is that on this occasion, The President of the College, The Master of The Barbers and the Lecturer are orthopaedic surgeons. Clare Marx is the first female President
first presented his line to the medical profession. It will be interesting to note if any of these references creep into the orthopaedic literature
of the College and Sir Roger Vickers, like Thomas Vicary, a Sergeant-Surgeon to the Monarch, is the
Yours faithfully,
current Master of The Barbers (Fig. 1). The lecture is a public event but the core audience comes from the Council and Court of
4. Bertwistle AP. A Descriptive Atlas of Radiographs of Diseases of the Bones and Joints. Pub. Bristol, John Wright and Sons; 1924:38.
”
David Jones davidhajones@hotmail.co.uk
the College and Court respectively (Fig. 2).
Fig 1. Clare Marx, David Jones and Sir Roger Vickers, flanked by the mace-bearers of the RCS (left) and Barbers (right)
Fig 2. The Vicary Lecture in progress
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BJJ News | I ssue 5 | D ecember 2014
Obituary
Professor Louis Solomon
Prof Einhard H.W. Erken
1928-2014
A tribute to a ‘guru’ of orthopaedic surgery
n the leader of the Festschrift for the 50th Anniversary of the Wits (Witwatersrand) Depar tment of Orthopaedic Surgery in 2012, Professor Louis Solomon looked ‘Through a Window Brightly’ (the title of his contribution), and asked: ‘How many acorns do you have to plant to grow a forest of oaks? One? A thousand?’ (www.orthowitsalumni.co.za). Louis Solomon was educated at the South Africa College Schools (SACS) in Cape Town, where he also studied medicine at UCT. He became an orthopaedic surgeon, training in London, UK and Boston, USA. Prof Jock Edelstein, the first incumbent to the Chair of Orthopaedics, appointed Louis consultant orthopaedic surgeon to the Department of Orthopaedic Surgery at Wits in 1966. Solomon took over the Chair of Orthopaedic Surgery in 1968 and headed the department until 1986.
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Louis had the rare gift of bringing out the best, both ideas and passion, in the people with whom he started new developments in an academic department. There were no facilities or staffing for basic research, but clinical orthopaedics had already spread its net far and wide: from the old Johannesburg General Hospital, to the Transvaal Memorial Hospital for Children, the J.G.Strydom Hospital, Baragwanath Hospital, Coronation Hospital and the Hope Convalescent Home for Crippled Children. Fully skilled and dedicated orthopaedic surgeons were already working in these six teaching institutions. They were the chiefs of the teaching and training units which included a hand surgery unit, two paediatric orthopaedic units, many trauma units, many ‘cold’ orthopaedic units, a bone and joint sepsis unit, two spinal surgery units, some arthroplasty centres and a metabolic bone disease unit. Louis widened our orthopaedic horizon when he started a Bone Tumour Registry, Rheumatism and Arthritis Unit, and later the Chris and Daphne Petrow Orthopaedic Research Laboratories and the Cartilage Research Laboratories. In 1982 he founded the South African Arthritis Foundation. We, the orthopaedic registrars on the Johannesburg four-year training programme (called ‘royal game’), began to realise that orthopaedic surgery could be more than a quintessentially hands-on discipline, as it was at that time. Louis Solomon roped into his department the talents of colleagues and scientists from other academic disciplines: physicians, paediatricians, physiotherapists, haematologists, occupational therapists, geneticists, anatomists, paleoanthropologists, rheumatologists, plastic surgeons, nephrologists, radiologists, metallurgists, orthotists and prosthetists,
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microbiologists, epidemiologists, nurses, social workers, statisticians and accountants. Some called it Solomon’s menagerie (from the original 18th century French, meaning household management).Visitors to our department were amazed, often gaped and asked ‘does such a melting pot of academia, science, craft, art and healing still exist?’ It did. It was truly Solomonic. His enthusiasm for teaching, reading and writing was infectious. Look, feel, move became a popular guide for the physical examination of patients. It had been introduced into the teaching of clinical methods by the late Alan G. Apley, first in the FRCS courses at Pyrford and later into a printed textbook of Apley’s
System of Orthopaedics and Fractures in the mid-1950s.
like beads on a string. He convinced us that language begets thinking. He made us think orthopaedia. In 1982 he gave the Robert Jones Lecture at the 7th Combined Meeting of the Orthopaedic Associations of the English-Speaking World in Cape Town. The title was ‘Osteoarthritis – Peeling the Onion.’ There he peeled off layer after layer of the patient’s disorder or illness, to lay bare the core: the person behind the disease. ‘What do you think of the Professor?’ the lady, who had just been ‘fitted’ with a total hip replacement prosthesis, asked her bed-neighbour. ‘You know, the Grand Round, chatter, chatter, chatter, medical jargon and stuff. But the Professor always treated me like a human being; he is a real mensch.’
Louis had an impeccable career and was the reason behind evolving the careers of many orthopaedic surgeons to date.
Louis Solomon co-authored the sixth edition (1982) of this very popular orthopaedic textbook and added to it his rich and colourful South African experience of the Johannesburg department. The text was designed to be used by postgraduates and their teachers, by undergraduates, by trauma casualty officers, by general practitioners who sought further understanding of their orthopaedic patients, and by colleagues in the allied professions. The textbook, enlarged by many co-authors, has grown in size (and price) to its 10th edition, now termed an ‘International Student Edition’. One can take from the book the ‘look, feel, move’ as cues rather than imperatives, taking it from the lecture theatre to the fellowship and examination rooms to the patients. We didn’t realise that Louis Solomon taught the habit of thinking in a hierarchical way rather than stringing pieces of knowledge together in a continuous line,
‘Great oaks from little acorns grow’ was Louis Solomon’s vision for his Department of Orthopaedic Surgery at Wits. He wrote in his contribution for our 50th Anniversary in 2012 ‘I believe we did start to grow a forest’. He left Johannesburg 28 years ago; first, to take up the Foundation Chair of Orthopaedic Surgery in Bristol, and later, after retirement, to contribute to academic orthopaedics in the orthopaedic communities of the English-Speaking World. He is survived by his wife Joan, his daughters Caryn and Joyce, his son Ryan, and his grandchildren.
A uthor
details
Prof Einhard H.W. Erken
FCS(SA)Orth, Emeritus Professor of Orthopaedic Surgery at Wits.
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BJJ News | I ssue 5 | D ecember 2014
Obituary
John Fixsen
1934-2014
John Fixsen, children’s orthopaedic surgeon, sailor, skier, balletomane and much more, died suddenly and unexpectedly on 11.8.14 at his home in Devon. His influence and involvement in many spheres, both national and international, will be greatlywmissed. A memorial service was held on 23rd October at St Bartholomew the Great and was attended by his family and many friends. While the Bone and Joint Journal has published a formal obituary, we thought it appropriate to present an appreciation of this remarkable man.
S
arah Stacey (John’s daughter) writes:
Dad was a man of many passions – medicine, clearly, but also so many other things: reading, classical music, ballet, sailing, skiing, cars (particularly fast cars) climbing (which as he got older became walking) and he was endlessly generous in encouraging others to enjoy any of these hobbies. So many of our friends were introduced to skiing, ballet, sailing and great meals, all courtesy of Dad. He was also generous in supporting charities – the RNLI always, but also so many others ranging from Barnado’s to the Campaign for the Protection of Rural England, but mostly those that actively focused on supporting children or young people in practical ways.
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He always came across as a modest and unassuming person – as children we had no real awareness of how successful he was in orthopaedics nor how competitive he was (although this became apparent when we were foolish enough to play squash with him when we were in our teens – and spent the whole time hurtling round the court as he commandeered the middle of the court and barely moved!). However his competitive side was driven by a need to do his best in all activities in which he participated rather than being the best of all. He never made us feel that his level of achievements were something he felt we should be aspiring to. He was kind and compassionate and believed in treating others as you would like to be treated yourself.
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He rarely criticised or judged others – if people did things that seemed terrible he would always try and consider how he would have behaved in the same circumstances. He was in some respects, unworldly, and a little eccentric – he definitely was not concerned with material comforts or belongings and kept everything! He seemed to live in a slightly different (and rather lovely) world doing the things he loved and ‘tolerating’ the modern world (mobile phones, email, PCs). He was always supportive of us, his children, whichever path we chose. With his grandchildren he attended pantomimes and theatre productions (and genuinely enjoyed them) and was always appreciative, if a little bemused, by Tom’s magic tricks and knowledge of computers. He never did quite master the art of a conversation being a two-way dialogue with both parties contributing equally…. However this was only because his knowledge was so wide and diverse and he had so much to impart! He continued to live life to the full after his much loved medical career, so it seems appropriate to finish with a quote we found in his current diary – handwritten by him. It is a quote from Marcus Aurelius: ‘A man’s true delight is to do that which he was made for’ …and Dad certainly did. David Jones, John’s successor at Great Ormond Street writes: I first met John in 1970, when I came from Manchester to RNOH Stanmore as an SHO. The Registrars and Senior Registrars were destined to be included in the pantheon of British orthopaedics and included Catterall, Colton, Edgar, Dandy, Laurence, Hall, Ransford and certainly not least, Fixsen. He was not the tallest (Ransford was), but obviously had great energy, intellect and surgical ability. He had been brought up in Altrincham and excelled at Manchester Grammar School, so we had plenty to talk about, mostly on his side, over the operating table and socially, including games of squash, which he played ferociously and, I’d like to remember, not quite as well as me. When he left school, he was due to go to Magdalene College, Cambridge to read Zoology, but beforehand was in the last batch of National Servicemen and commissioned into The Royal Navy, where he learned Russian and worked as an interpreter. In 1955 he went up to Cambridge, where he switched to Medicine, going to The Middlesex Hospital for clinical studies in 1958 and qualifying in 1961. During his house jobs there, he came under the influence of Philip Newman in particular, settled on a career in orthopaedics and never looked back. At the time I left RNOH he had been appointed Consultant at Barts and when I was appointed there as a Registrar in 1972 he was already making a name, not only as a surgeon, but also as a teacher and mentor. Towards the end of my training, I worked for him at GOSH, Hackney, Barts and Tadworth which is a reflection of his energy and commitment to these institutions. My time with John helped give me the experience and enthusiasm to take a special interest in children’s orthopaedics. It was obvious John would become recognised nationally and internationally, and so it was.
I spent my first 17 years as a consultant in North Wales and Oswestry, during which we met frequently at courses and meetings and when it was announced that John was to retire in 1996, it was an honour to be considered as his successor, although he was an impossibly hard act to follow. I greatly appreciated his support before and after moving to GOSH and we were able to have a year where we shared clinics and lists, without which the learning curve into his practice would have been too steep. In his clinics the children referred to him as ‘Mr Fixit’ and he took on the most complex cases, which gave great support not only to the children and their families, but also the surgeons who referred cases from far and wide. He was a long-term examiner for the Edinburgh and later the Intercollegiate Orthopaedic Fellowship and I had the dubious privilege of being examined by him in 1990. He also gave sterling service to The Journal of Bone and Joint Surgery, firstly as Editorial Secretary of the BOA, then as a long term reviewer, Board Member (1982-85) and highly valued Associate Editor and rewriter from 1997 to 2011. By the time of his retirement I think he was the unsurpassed as a children’s orthopaedic surgeon in the UK. Apart from his clinical and surgical abilities he had published widely in books and journals, given countless presentations and invited lectures, including the Robert Jones Lectureship in 1994 and served the British and European Children’s Orthopaedic Societies with distinction. He was also a Civilian Consultant to The Royal Air Force. His international reputation was cemented as an invited member of the International Paediatric Orthopaedic Think Tank. For all the achievements in his orthopaedic career, including his work in Afghanistan, he was awarded the Honorary Fellowship of the British Orthopaedic Association in 2010. Jeanne Hartley (Sandy Gall’s Afghanistan Appeal) writes: In 2002, John was invited to Afghanistan as medical advisor to Sandy Gall’s Afghanistan Appeal, working with Afghan nationals trained by the charity as physiotherapists, orthotists and prosthetists in clinics in Kabul and Jalalabad and later in other provinces in the north of the country. These busy clinics catered for many Afghans with disabilities caused by 30 years of war, but John quickly realised that little attention was being given to the children, who presented to the clinic, with untreated congenital conditions as well as polio, CP etc. John’s contribution to the very successful Ponseti and the DDH screening programmes has resulted in preventing disability for many, giving them a better chance in life. Over the years he made a marked difference to the lives of many Afghan children with disabilities, not only by his excellent surgical skills but more importantly by identifying the few Afghan orthopaedic surgeons who showed an interest in paediatric problems. He then nurtured and inspired them, improving their clinical and surgical skills, giving them unstinted attention and support. He generously arranged opportunities for further training outside the country and donated surgical instruments and textbooks. The many message of condolence sent from Afghanistan stand testament to the impact his time there had on the lives of many in a country he loved.
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BJJ News | I ssue 5 | D ecember 2014
Rob Hill (Consultant Orthopaedic Surgeon, GOSH) writes: I was student, houseman, senior registrar and consultant at Bart’s as well as being consultant both at Queen Elizabeth Hospital Hackney and Great Ormond Street. At all these stages I was in contact in one way or another with John Fixsen. He taught me as a medical student in the fracture clinic at Bart’s but I came to know John more as his houseman, and later senior registrar. He was Mr Fixsen to me as a student, and JAF, well not to his face, as houseman and registrar. In those days we took trauma at Bart’s and John used to live in on-call at least in the week in the James Gibb flat next to the Great Hall. He tended to work in his office in the evenings preparing a lecture or perhaps an article, and maybe we used to bother him more than was strictly necessary knowing that his advice was always nearby. Perhaps because of this he always had the most junior of the registrars to work for him. There was actually a very wide range of work at Bart’s as he seemed to have a lot of little niches apart from paediatrics. He used to do routine primary Stanmore hip replacements, but no knees. He took on orthopaedic surgery for renal dialysis patients and sickle cell adults. There was an interest in Ewing’s sarcoma of the fibula and foot surgery. As I was to learn later, paediatric orthopaedic surgeons often end up doing adolescent and young adult foot surgery as the origins of pathology are often in childhood. He talked quite a lot and encouraged research. John enjoyed working at Bart’s; his choice of tie was usually the Pott Club tie. He encouraged the development of the Pott rotation and attended its dinners regularly.
After a list there was always a post-operative ward round, and the invitation, if of course we did not have to get off home, for a half pint. At Bart’s it was ‘The Hand and Shears’ and later when I was senior registrar at Great Ormond Street it was ‘The Lamb’. By the time I was appointed consultant at GOS and Queen’s Hackney, John worked at GOS, some satellite clinics, and Bart’s. Potentially this was a difficult time for me, and for five years it was, but not because of John: he struck just the right balance of being available to help and letting me get on with it. He returned to Queen’s every Monday morning to go through the cases with me; it was he who encouraged my interest in Ilizarov, and helped me get an honorary contract at Bart’s later which became substantive sessions for a few years at least. There is one thing in particular I will always be grateful for: that is, as a newly appointed consultant at GOS he never asked me a question at the Wednesday morning conference which would have revealed that I had not read so and so’s seminal paper from 1980. I remain amazed at his memory for papers, rare conditions, and his ability to give shrewd comments from experience. When Professor Shetsov, Ilizarov’s successor, visited us at Great Ormond Street, the Russian that he had learned many years before during National Service came back into use, to everyone’s surprise.
It is John’s memorial that he brought hope to many, and enabled others to do the same by teaching so that even now, after his passing, his work is still felt.
www.boneandjoint.org.uk
Editor-in-Chief, Bone & Joint Research The British Editorial Society of Bone & Joint Surgery is seeking to appoint a new Editor-in-Chief for its open access journal, Bone & Joint Research (BJR), when Professor Andy Carr steps down in early 2015. Professor Carr, BJR’s founding Editor, has successfully established the journal over the last three years; it is included in PubMed Central and PubMed, and has recently been accepted for indexing by Web of Science from the first issue, so will have its first Impact Factor for 2014 which will be announced in June 2015. BJR publishes papers across the whole field of musculoskeletal science, from basic science studies to clinical research. All papers are published under the “gold” open access model, with an Author Publication Charge (APC) payable by the authors or relevant funding body. We now seek a new Editor-in-Chief to build on the success of BJR to date, and to make this journal the leading open access publication in orthopaedics. The successful candidate will be an orthopaedic surgeon or musculoskeletal scientist with an active research programme, with previous editorial experience on the boards of other journals, and as a reviewer. The Editor is supported by a strong professional in-house publishing team, and it is expected that his/her duties will occupy about half a day per week initially, which is likely to increase with the growth of the journal. An honorarium is payable for this position. A full job description is available at www.boneandjoint.org.uk/content/supplement/editor-chief-bone-joint-research Deadline for applications: 31st December 2014. Interviews will be held in late January 2015. To apply, please send a covering letter and CV to: Peter Richardson, Managing Director, British Editorial Society of Bone & Joint Surgery, 22 Buckingham Street, London WC2N 6ET. Email: p.richardson@boneandjoint.org.uk
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