BJJ News Issue 11 by BoneandJoint

BJJ News | I ssue 9 | D ecember 2015

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BJJ News | I ssue 11 | D ecember 2016

Issue 11

Current Concepts

Orthopod’s view

The ‘winter crisis’, cancellation of elective orthopaedic operations and its impact on training: the role of the independent sector J. Palan

Current state of robotics in knee surgery G.G. Jones & J. Cobb p12

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BJJ News

Issue 11

from The Bone & Joint Journal

December 2016

Editorial Editorial

A. Ross

What I wish I had known when I started in orthopaedics

C. Faux

The ‘winter crisis’, cancellation of elective orthopaedic operations and its impact on training: the role of the independent sector

J. Palan

Current controversies in shoulder surgery

S. Lambert

The London Implant Retrieval Centre: what has it done and is retrieval analysis worthwhile?

J.A. Skinner, H.S. Hothi, J. Henckel & A.J. Hart

Current state of robotics in knee surgery

G.G. Jones & J. Cobb

Changing the operating surgeon: specific consent required

N.V. Todd

J.A. Shelton, S.R. Platt & BOTA Linkmen Collaborative

European Knee Society 2015 Travelling Fellowship

S. van de Groes, P. Monk, M. LindbergLarsen & S. Cerciello

The Mark Paterson Travelling Fellowship 2016

D. De Kam, O. Kubat & M. Stiehler

The Charnley Latta Travelling Scholarship report

K. Singisetti

J. Ridge

G. Bentley

Orthopod’s view

Current Concepts

TRAINING Teaching snapshot: a qualitative and quantitative review of higher orthopaedic teaching programmes in the UK

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

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Letter A response to the Editorial on junior doctors (BJJ News, Issue 10, August 2016)

Appreciation George Dowd 1946-2016 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 4.0)

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BJJN00000028 editorial2016

BJJ News | I ssue 11 | D ecember 2016

A. Ross

Editorial

JJ News may be a relatively slim volume but its editor is, without doubt, not of the same bodily habitus. Consequently, he finds himself disappointed that various clinical commissioning groups throughout the country have decided that they will ration the provision of joint arthroplasty, among other procedures, to those who are obese or, more precisely, to those with a BMI of 30 or higher. This is clearly a political decision, as it studiously ignores the existing evidence base. What is the evidence? Those who are overweight have an increased risk of developing osteoarthritis of the knees1,2

and, to some extent, the hips.3 This appears to be a mechanical rather than a systemic factor. A rapid increase in weight increases the risk of total knee arthroplasty more than being constantly overweight: heavy physical work also increases that risk.3 On the whole, patients with osteoarthritis of the hip or knee tend to be less active, or in orthopaedic parlance function at a lower level, than those whose BMI is within the normal range. Consequently, although they achieve a lower functional outcome after total joint arthroplasty than those of normal BMI, their degree of improvement is nonetheless comparable.4 Nor, until the BMI exceeds 40 kg/ metre2 is the rate of complications significantly higher5. (You will note that I have deliberately chosen relatively old references. This is not new knowledge: it has been around for many years.) This appears to be yet another method of rationing necessary treatment to patients with painful and disabling conditions. It is superimposed on the now seemingly ubiquitous practice of ensuring that all patients with musculoskeletal problems are first referred, inevitably after a period of delay, to a physiotherapist rather than to a rheumatologist or orthopaedic surgeon. They then embark on a ‘pathway’ of treatment. If this fails, there is then further delay before they are referred on for tertiary care. In the case of patients with established osteoarthritis of the lower limbs, the Oxford hip or knee scores are often worse after ‘treatment’ than before they started; in other words, time has been wasted and expense incurred. This is a particularly pernicious piece of bureaucracy in the case of patients with low back pain who, if prevented from working because of their back pain, are increasingly unlikely to return to their premorbid job as their length of time off work increases.6 The additional macroeconomic effect of this is considerable. Low back pain was estimated to cost the country £12.3 billion per annum 16 years ago. Only £3.2 billion of this were direct costs. The rest was lost to the economy.7

While it is clear that the NHS is perennially short of resources, and its clinical staff, particularly junior doctors, are leaving in droves for reasons that are clear to all of us, it cannot be beyond the wit of those who ‘manage’ the service to see that treating patients promptly and appropriately is cheaper in the long run than delaying treatment for spurious reasons. I suppose that some patients will die in pain while waiting for treatment but most will end up having their operation, albeit at a later date. Does this really save money? Despite all these shenanigans, the season of goodwill is approaching. Your editor resolves to pay full attention to the joys of the family table and to renew his private health insurance. In the meantime, I would like to thank all those who have contributed to BJJ News this year and to all who have read it, particularly those who have been kind enough to write to me in appreciation of its content. Happy Christmas. References 1. Felson DT, Anderson JJ, Naimark A, Walker AM, Meenan RF. Obesity and knee osteoarthritis. The Framingham Study. Ann Intern Med 1988;109:18-24. 2. Stürmer T, Günther KP, Brenner H. Obesity, overweight and patterns of osteoarthritis: the Ulm Osteoarthritis Study. J Clin Epidemiol 2000;53:307-313. 3. Flugsrud GB, Nordsletten L, Espehaug B, Havelin LI, Meyer HE. Risk factors for total hip replacement due to primary osteoarthritis: a cohort study in 50,034 persons. Arthritis Rheum 2002;46:675-682. 4. Griffin FM, Scuderi GR, Insall JN, Colizza W. Total knee arthroplasty in patients who were obese with 10 years followup. Clin Orthop Relat Res 1998;356:28-33. 5. Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg [Am] 1998;80-A:1770-1774. 6. Waddell G. The back pain revolution. Second ed. Edinburgh: Churchill Livingstone, 2004. 7. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95-103.

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

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BJJ News | I ssue 11 | D ecember 2016

C. Faux

ORTHOPOD’S VIEW

What I wish I had known when I started in orthopaedics

rought up in a single-handed GP practice where Dad also had a job as a GP/surgeon was my introduction to medicine. The family were all involved with the practice, which was run from home with consulting and waiting rooms in an old stable. Surgical emergencies were dealt with; before university I had seen several acute appendix and hernia operations. My life was concerned with Meccano, a 1935 Rover 10, a rugby ball, a tennis racquet and, of course, girls. Dad had an interest in orthopaedics, having worked with both Robert Jones and Thomas Porter McMurray during his training at Liverpool. I soon realised that medicine had changed and I would have to choose between being a GP or a hospital practitioner. A couple of accidents introduced me to orthopaedics. A shoulder injury playing rugby and, six months later, a road traffic accident with multiple injuries which required admission as an emergency to the Birmingham Accident Hospital in 1959. Not only was I treated superbly and a post-operative pulmonary embolism recognised and treated after research done on site by haematologist Dr Sevitt and my consultant, Ruscoe Clarke, the hospital also left a lasting impression. Here we found superb organisation, discipline, camaraderie and teamwork. There were three teams and all had their own physiotherapists, radiographers and ward. On call was one in three and at weekends Sunday lunch was ‘in-house’ when all staff attended, including the consultants. The name of William Gissane was imprinted firmly in the psyche of all. The surgeons concerned at this time were general surgeons with a special interest in trauma and, like the founding members of the AO school, were effectively ‘bone and belly’ surgeons. Everyone wore a white coat with name and status tag on it clearly denoting to whom one was talking at all times. The hospital, which should have been used as a template was, of course, closed later and some 50 years on we are now recommending specialist accident centres throughout the UK! My training in Liverpool was traditional and in orthopaedic surgery very conservative. All students had a three-month spell in orthopaedics;

our teachers were excellent and history and examination was paramount. Lord Cohen’s dictum that a proper history gives the diagnosis which can then be confirmed by examination rang in all ears and a large modicum of common sense was instilled. For example: “If you hear clip-clop in Pembroke Place is it likely to be a horse or a zebra?” and “Certainly sparrows are more common than canaries.” Another one which sticks in the mind was: “A gumma is still a gumma on a bishop’s leg”. Case notes were hand-written, apart from operation notes which were typed in red. Daily recording by doctors plotted the progress of recovery. Ward sisters were the lynchpin of the service. They were very experienced, practical, in their mid-40s and truly vocational. They could not only help and mentor uncertain juniors but also answer patients and relatives questions with ease. Most had no desire to be matrons or administrators and were happy to manage their own patch and ‘firm’ with both discipline and understanding. The AO school started in 1960, almost exactly a year after Charnley’s book, ‘The closed treatment of common fractures’, had been

published. Initial AO courses in the UK started at a Technical College in Stoke, rapidly transferring to Oswestry after about three years. It was some time before the value of these courses hit London and the excellent later courses organised at the Royal College of Surgeons by AG Apley whose ‘Systems of orthopaedics’ was a best seller and whose maxim of “look, move, feel, strain and x-ray” became the mantra of that generation of orthopaedic students. My 18-month surgical fellowship training included time at Whiston Hospital where the first intensive care unit in the UK was to be found. The registrars were involved in this and assisted with any surgical procedures, such as cut-downs. This rotation included six months of orthopaedic surgery where the consultants were getting to grips with total hip arthroplasty and researching a shoulder replacement. My two predecessors on this rotation had moved on to the General unit at Wrightington and gave glowing references for the experience and their exposure to large numbers of orthopaedic problems. I applied, was successful and started work in January 1974. I found again a mirror of the ethos of the Birmingham Accident Hospital. My boss, Keith Barnes, was the surgeon superintendent and had trained under Professor Gissane at the Birmingham Accident Hospital! Discipline and organisation were paramount. The firm consisted of him and me. Like the Hip unit, there were Fellows and no other junior staff. Patients were clerked in, operated on and checked out by a team of two. The other hip Fellows were mainly from overseas and they and their families lived on site. Firm dinners and biannual lunches at the Charnley home led to a family feeling, and the foundation of the Low Friction Society. The first English meeting of the Society was in May 1974. Even though I worked on the General unit, I was included and invited. We had many happy evenings at the social club which also included an area of sprung dance floor (which covered the original indoor riding school). The General unit looked after skeletal tuberculosis for the North West. We had 100 new patients that year, mostly of Asian background

BJJ News | I ssue 11 | D ecember 2016

and children. There was a dedicated childrens’ ward with a school and three teachers on site. Mr Barnes’ work included total hip arthroplasty, tertiary referral back surgery, local general orthopaedics and sports injuries from both Wigan and Blackpool. It was busy: operating lists frequently exceeded 20 patients. My job also involved looking after cold orthopaedic admissions and surgery for two Preston consultants, a certain Mr R. S. Garden and Barrie Case, as there were at that time no cold facilities in Preston. After twelve months it was all over. Lasting memories of efficiency, organisation, 250 beds, one hospital secretary, one superintendent and no other administrators. Discharge letters went out on day of discharge. Case sheets were three to four pages only. Radiographs were available in clinic, and previous radiographs displayed on a box for comparison as the patient was seen. Four consultants, seven juniors, no nurse practitioners. All patients were seen initially and post-operatively by experienced, medically qualified staff, who looked you in the eye and gave their opinion, not a list of eight options or possibilities. Eighteen months later I was back for six months as a Senior Registrar. Little had changed. One more consultant had been appointed. The Salmon Report had been implemented and the nursing hierarchy had been turned on its head. The tradition of the hospital continued and the boss, John Charnley, was very much in evidence. He resigned from the NHS after the Salmon Report but continued his research. In 1977 I was appointed to Preston and Chorley. I inherited a waiting list of three years! There were no facilities for cold orthopaedic surgery and no enclosure. With my two colleagues we set about building a unit in the old ‘Poor Law’ hospital at Sharoe Green. We had a large day ward as well. Throughput was dramatic and became the second highest in the UK. Our waiting list dropped to three months. We found some extra money from the Waiting List Initiative and used it to get an extra half day’s anaesthetic cover for our lists. We were never short of registrars in training: they queued up to join. Two new extra consultants were appointed and there was no division into sub-specialisation at this stage. Yes, we had audit. Yes, we had clinical directors and MAC meetings but all of these were

held outside working time, usually at 5:30 pm or 6:00 pm. We had separate firms. We had parties, dinners, visited each other’s homes and looked after medical students from Manchester. We also hosted the MCh Orth students from Liverpool. It was busy, it was fun, it was a family and no one took or wanted early retirement. Morale was high. So what has happened since? Clearly we need more doctors. Since 1948 the Health Service has been propped up by many doctors from both India and Pakistan. Successive reports have never woken up to the numbers required for the huge advances in medicine and the increasing numbers of elderly, even though this was highlighted as long ago as 1980 in a paper to the GMC. Presumably the inaction and deafness to this particular paper was entirely related to cost. It appears we now have 40 000 administrators. In many cases they appear to be paid much more than consultants. They have a team of secretaries and assistants who appear to have endless meetings, producing very little. Knowledge of medicine appears to be minimal and all plans are based on finance. Like David Jaffray at Oswestry I would avoid administration duties as no one listened and were only interested in money, not patients. Separate units for cold orthopaedics have been routinely closed and only a few now remain. The excellent Harlow Wood was persuaded to move into the local district general hospital and immediately problems started as cold orthopaedic beds were used for emergencies. This makes the planning of weekly admissions extremely difficult. Consultant lists were organised by administrators, not surgeons. The original job was done by me and my secretary but now required a staff of nine who are more concerned as to whether the patients were from fundholding practices, non-fundholders or outside the general area. On our unit, all patients were known and it was possible to balance the numbers coming in with the appropriate staff available for the following week. Cases were rarely cancelled. Over the years I notice, on my visits to Wrightington, that anaesthetic downtime had vastly increased. In 1974 we were doing six total hip arthroplasties a day per theatre. In 1976 this was down to four and when I went back in 1999 it was down to three. Down time

varies from hospital to hospital but seems to be about an hour. Having worked in the US where one doctor can control five or six theatres with appropriate anaesthetic assistant staff, I cannot understand why this system has not been adopted in the UK. I am fully aware of the paramount need for safety, but also appreciate that theatre time is very, very expensive and should be used to its maximum. The European Working Time Directive has been a complete disaster and has reduced the time available both for operating and for proper training. It has removed the ‘firm’ structure and diluted any hub or community spirit, leaving trainees isolated and apparently not properly mentored. Daily handover sessions lasting an hour or so were never necessary – we all knew our firm’s patients. In my current role I triage GP referrals for musculoskeletal conditions. We are seeing about 1800 patients each month: 48% are being treated in the community and not in hospital. The patients are very happy. The standard of referral is sketchy and suggests history is minimal and examination frequently not at all. I am reminded of two stories from my mentor, Guy Almond, at Broadgreen Hospital, Liverpool. A GP letter stated: “Please see right leg”. His reply was: “Right leg present”. An MCh Orth student was asked in the 1960s what had impressed him most on the course, to which he replied “The no-touch technique”. Guy was surprised by this and said we hadn’t used the no-touch technique in the theatre for many years. “No” said the candidate, “Not in the theatre - in the GP surgery”. More worrying is that the MSK patents – 900 per month – are not being seen by either medical students or trainee GPs; a recipe for disaster in my view. I have reported this repeatedly to the BOA, the local Deanery and to the company, without any action being taken. In answer to the question – would I do it again? - of course I would. I have loved every minute of it, but I am concerned that matters are deteriorating over time, and cannot see how the NHS can continue in its present format. A uthor

details

Christopher Faux FRCS(G) chrisandpattifaux@btinternet.com

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BJJ News | I ssue 11 | D ecember 2016

J. Palan

ORTHOPOD’S VIEW

The ‘winter crisis’, cancellation of elective orthopaedic operations and its impact on training: the role of the independent sector

he media are paying close attention to Accident and Emergency (A&E) services, which are buckling under increasing patient demand compounded by a lack of hospital beds and staff shortages. The warning signs were present as far back as January 2015 when The Guardian published an article entitled ‘A&E meltdown forces thousands of operations to be cancelled’ (Fig. 1).1

The knock-on effect of this has meant that elective operations have been cancelled in order to free up hospital beds to accommodate the ever-increasing admissions from A&E. Data from NHS England show that in the quarter ending March 2015, 1.1% of all elective operations were cancelled, compared with 0.9% over the same time period in 2013/14. Of these operations, 8.7% of patients were not treated within 28 days of the cancellation compared with 4.7% in the same time period in 2013/14.2 Unfortunately, elective orthopaedic operations are extremely vulnerable to cancellation as the vast majority are not life- or limb-threatening, even though the cancellation of such procedures leaves thousands of patients with pain and disability. In the UK, many hospital trusts are putting contingency plans into place to provide more ‘escalation ward’ areas to cope with the ‘winter crisis’ bed pressures. This has led to orthopaedic wards being used to accommodate acute medical patients and to elective orthopaedic operations being cancelled. In particular, operations such as total hip and total knee arthroplasty (THA; TKA) which require in-patient admission for a few days, have been adversely affected. The net result has been that waiting times for elective THA and TKA have increased to several months or more, making a mockery of the government Referral to Treatment (RTT) target of 18 weeks.3 Indeed, some hospitals have now stated that from January 2017 to March 2017, elective orthopaedic wards will be used for medical admissions and not for elective orthopaedic patients. This will have a significant impact not only on patients, but also on trainees in trauma and orthopaedics.

Trainees are expected to have a minimum of 40 THAs and 40 TKAs as part of their indicative numbers for index procedures, in order to meet the requirements for their Certificate of Completion of Training (CCT). If training posts in lower limb arthroplasty are affected by the widespread cancellation of elective THAs and TKAs, this will have an impact on trainees and their ability to meet these requirements. Hospital trusts are faced with an impossible task in trying to cope with the increase in inpatient admissions while maintaining elective work; as usual, service needs override training requirements in the interests of patient safety. This is all very well on occasion when there are exceptional patient demands which the system cannot handle, but the reality now is that such occasional situations have become the norm, with hospitals frequently on red or black alert with no spare bed capacity. The so-called ‘winter crisis’ seems to be never-ending and irrespective of season. Unfortunately for hospitals, this is a double whammy. Not only do trusts take a financial penalty for breaches of A&E four-hour targets, but by cancelling elective orthopaedic operations at the last minute due to a lack of beds, they face the added financial hit from a loss of revenue and further penalties if they fail to offer the operation within 28 days. A report from Bristol estimated that a single trust lost up to £700 000 in seven months as a result of last-minute cancellations in elective orthopaedic surgery.4

The difficulty now facing trainees is that irrespective of the crises facing hospitals, we are still expected to gain experience in elective orthopaedic surgery. It may not be possible under the current model of working and training within the NHS to acquire such experience. A new way forward is needed which takes into account the changing face of the modern NHS and the fact that independent providers and ‘patient choice’ are now an integral part of the NHS. Independent sector treatment centres (ISTC) have been in existence in the NHS since 2003 and second-wave ISTCs are contractually obliged to ensure that at least one-third of all activity is available for the training of junior medical staff.5 Because of the increase in the number of NHS patients going through the ‘choose and book’ system who have their operations in independent sector hospitals, there have been concerns that the more straightforward cases are being carried out in these centres without the opportunity for trainees to be trained. A 2008 study by Clamp et al showed that there was a statistically significant reduction in elective orthopaedic operations taken by T&O registrars after the introduction of an ISTC in the local region.6 The Royal College of Surgeons of England (RCSE) have also raised concerns that the independent sector is not doing its part in ensuring that training takes place in their centres. In 2013, the RCSE published a report which highlighted the issues facing surgical trainees, and the lack of opportunity in accessing routine surgical operations which are increasingly being carried out in independent centres.7 A study by Parmar, Armstrong and Drysdale looked at ENT surgery in ISTCs and found that of the 24 ISTCs contacted who undertook elective ENT operations on NHS patients, none had an ENT surgical trainee.8 In light of all of these challenges, there has to be a fresh approach to how operative experience can be delivered. One way would be to engage with the independent sector to enable trainees to accompany their trainers, undertaking elective operations as part of their training timetable. If the independent sector is being

BJJ News | I ssue 11 | D ecember 2016

Fig. 1 Report on cancelled operations, The Guardian, 10 January 2015. 1 paid by the NHS to carry out elective operations on NHS patients, then it also has a duty to provide opportunities for training. This should be recognised and enforced in any negotiations between the independent sector and NHS England. As set out in the Health and Social Care Act 2012, independent sector providers are compelled to be responsible for the effective delivery of commissions agreed between Local Education Training boards (LETBs) and Health Education England, which includes the appropriate availability of clinical experience and education. NHS hospitals which have trainees should ensure that if elective work has to be outsourced to independent sector providers, then local agreements between the NHS trust and the independent sector hospital and LETBs should be in place to allow trainees to undertake operative work in the independent centre. If the NHS trust fails to ensure that such agreements are in place, then trainees should be withdrawn from that hospital. It is unacceptable for NHS hospitals to continue to receive funding for trainees from LETBs when training cannot be delivered by that hospital. The same applies to elective NHS outpatient clinics, since it would seem illogical to continue to see new patients in such clinics without having the capacity to list patients for surgery when the waiting times are approaching one year or more. If clinics are being held in independent sector hospitals for NHS patients, then trainees should also be allowed to attend such clinics as part of their training. The involvement of the independent sector in surgical training has already been piloted

successfully in the Wessex region. The Southampton NHS treatment centre is an ISTC based at the Royal South Hants Hospital and is run by Care UK. Since 2009, surgical trainees based in the Wessex Deanery have assisted at routine elective operations in orthopaedic and other surgical specialties in this centre, with excellent feedback on the training opportunities and experience available.9 This system may be a template for other training regions to follow. What appears to be missing in many regions of the UK is the impetus to ensure that independent sector providers allow trainees to work in their units, despite their legal obligation. It is time for decisive action to change the status quo in order to ensure that training requirements are not sacrificed on the altar of service provision in this never-ending ‘winter crisis’.

Procs 2012;94-B Suppl XII:17. http://www.bjjprocs. boneandjoint.org.uk/content/94-B/SUPP_XII/17 (date last accessed 4 November 2016). 5. Naylor C, Gregory S. Briefing: Independent sector treatment centres. https://www.kingsfund. org.uk/publications/briefing-independent-sectortreatment-centres (date last accessed 4 November 2016). 6. Clamp JA, Baiju D Sr, Copas DP, Hutchinson JW, Rowles JM. Do independent sector treatment centres (ISTC) impact on specialist registrar training in primary hip and knee arthroplasty? Ann R Coll Surg Engl 2008;90:492-496. 7. No authors cited. Royal College of Surgeons position statement on the role of the independent sector in education and training https://www. rcseng.ac.uk/about-the-rcs/government-relationsand-consultation/position-statements-and-reports/ surgical-profession/ (date last accessed 4 November

References

2016).

1. No authors cited. A&E meltdown forces thou-

8. Parmar A, Armstrong A, Drysdale A. ENT

sands of operations to be cancelled. The Guardian

training and the independent sector. RCS Bulletin

https://www.theguardian.com/society/2015/

2012;94:138-139.

jan/10/a-and-e-doctors-warn-patient-misery-

9. Rahman S. Working with independent sec-

planned-surgery (date last accessed 4 November

tor treatment centres to enhance surgical training.

2016).

BMJ Careers http://careers.bmj.com/careers/advice/

2. No authors cited. Cancelled elective opera-

view-article.html?id=20008704 (date last accessed

tions data. http://www.england.nhs.uk/statistics/

4 November 2016).

cancelled-elective-operations/cancelled-ops-data/ (date last accessed 4 November 2016). 3. No authors cited. Referral to treatment rules and guidance.

https://www.england.nhs.uk/resources/

rtt/ (date last accessed 4 November 2016). 4. Maclean AD, Bannister GC, Murray JRD, Lewis SM. Last minute cancellation of operations at a large elective orthopaedic hospital. Orth

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Mr Jeya Palan, East Midlands (South) Leicester Deanery, UK jeya_palan@hotmail.com

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BJJ News | I ssue 11 | D ecember 2016

S. Lambert

CURRENT CONCEPTS

Current controversies in shoulder surgery

n the current climate of increasing awareness that the conventional orthopaedic treatment of many conditions of the shoulder fails to deliver consistent outcomes, almost all aspects of shoulder surgery are under debate. Measurement tools are increasingly used to try to determine the efficacy and cost-effectiveness of interventions. Such tools are themselves subject to scrutiny: many are used in conditions for which they were not developed. The minimum clinically-important difference between scores at the outset and completion of treatment is unknown for many conditions: this may hide beneficial (or detrimental) effects of treatment, which may then be discarded for invalid reasons. A better understanding of molecular biology and immunology, as applied to degenerative and inflammatory conditions of the shoulder, has begun to challenge previous ‘certainties’ in fields as diverse as pain generation, tissue regeneration and cartilage degradation. Often, in orthopaedics, developments in technology, techniques and treatments follow emerging problems. Nowhere is this more relevant than in the important current, urgent interest in periarticular and periprosthetic joint infection.

cuff degeneration, the ‘knowledge’ that rotator cuff tear is an inevitably progressive disease (from so-called tendinopathy to partial tear to full tear), and the development of simple means to achieve an alteration in acromial morphology from what was considered abnormal to the more common surface and shape, led to the enthusiastic adoption of arthroscopic subacromial decompression as the treatment of choice for the relief of pain in the superior compart-

Controversy 1: Infection Propionibacterium acnes (P. acnes) is an aerotolerant, anaerobic gram-positive skin commensal which colonises the sebaceous glands of hair follicles of the epaulette region of the shoulder, largely after puberty. Through elaboration and secretion of proteases and collagenases, P. acnes damages the cell wall of the follicle. In doing so, pro-inflammatory cytokines are released which render local tissues more susceptible to opportunistic bacteria, including Staph aureus and S. epidermidis. P. acnes has been implicated in medium-term, so-called low-grade, periprosthetic joint infection (PJI), being found in isolates from joints at revision arthroplasty. However, it has also been found in joints at primary arthroplasty without previous instrumentation (including needling) of the joint. P. acnes has been implicated in the aetiology of some intervertebral disc disease: the bacterium produces propionic acid (hence its

Simon Lambert

name) which has been noted in (and is possibly causative of) the microfractures of the endplates of patients with disc disease. Antibiotic treatment of some patients with disc disease has been effective in reducing pain. It is uncertain what role P. acnes fulfils in the aetiology of primary shoulder arthritis. It is, however, clear that many cases of so-called osteoarthritis of the shoulder are unilateral, with no other predisposing factors. Is P. acnes the architect of the chondropathy? Does it render those shoulders more susceptible to post-operative super-infection with more invasive, and destructive, organisms, while rendering those organisms less susceptible to antibiotics? P. acnes is susceptible itself to antibiotic treatment. Many do not accept that it should inhibit the surgeon from performing a single-stage revision, or follow a debridement/antibiotic/implant retention regime in the treatment of low-grade, persistent post-replacement pain. The role of this organism in the pathogenesis of osteoarthritis, and in PJI remains obscure.

Controversy 2: Superior compartment shoulder pain The treatment of subacromial pain has been the raison d’etre of the shoulder arthroscopist since the technique was popularised by Ellman. The combination of the stenosis theory of rotator

ment of the shoulder. Many patients improved, but later critical review of outcomes suggested that the improvement was at least as likely to be due to the rehabilitation programme and to the passage of time, with an interested therapist on hand, treating the neck and shoulder together with alteration of life-style choices. Subacromial pressures can be raised in the absence of abnormal architecture of the subacromial space, and are therefore likely due to the deterioration of competence of the distal rotator cuff as a humeral head centralising structure with degeneration over time. Simply ‘raising the roof’ does not reverse the tendon degeneration. Perhaps, however, it does alter the rate of degeneration through other mechanisms. Clearly, removal of the periosteum and variable amounts of bone, and the coracoacromial ligament, denervates that part of the subacromial space leading to at least temporary pain relief until reinnervation occurs. It is common experience that pain returns after subacromial decompression in many patients after a period consistent with incomplete reinnervation. Recent evidence from biomolecular studies of the subacromial fluid and surfaces suggests that surgical damage to the periosteum of the acromion releases trophic hormones into the subacromial space which are positively correlated with better pain relief after surgery, and possibly conducive to tendon ‘healing’ or regeneration. That many patients are relieved of pain by arthroscopic surgery of the subacromial space is not in question; however the mechanism of analgesia is uncertain. The consequence of loss of the proprioceptive surface of the native acromion has yet to be evaluated, but it is appreciated that the inferior acromioclavicular ligament region is possibly

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the most densely innervated of the shoulder. Why this should be so is probably related to the evolutionary biology of human development, but its retention over epochs is interesting. The anatomy of the innervation of the shoulder joint has had little attention in the English language literature, with notable exceptions, and it is a German publication that can help us here. In 1963, Wilhelm1 published an extraordinary paper on the anatomy of the innervation of the shoulder, and the treatment of shoulder pain. Naturally this has received little or no attention in English language teaching, but offers crucial insights into why interventions might not work in some patients where they have before in others, and why some interventions (such as suprascapular nerve blockade for anterosuperior shoulder pain) might not work at all. It is essential reading for all shoulder surgeons and physicians dealing with so-called ‘cryptogenic’ shoulder pain.

Controversy 3: The rotator cuff Treatment of the natural history of rotator cuff degeneration consumes millions of health dollars a year. There is little doubt that repair of a torn but healthy tendon which goes on to heal is the best treatment for a painful tear of the rotator cuff. The difficulty we face is when and how to intervene in the evolving rotator cuff tendon condition: we cannot predict accurately or reliably which degenerating tendon will progress to a tear, or whether it will matter in the context of the shoulder as a whole. Clearly if injury is superimposed on a degenerating tendon and it ruptures, then repair back to its previous condition would appear logical. However, the difficulty in determining the depth and extent of partial tearing within a degenerating tendon makes decision-making about intervention in the pre-tear state controversial. Simply having the means to compress a partially-torn tendon back to its bony footprint, particularly if that bone is in itself insufficient (i.e. osteopaenic or incapable of elaborating trophic hormones for healing the enthesis) does not guarantee improvement in the outcome for the patient. Compression of the degenerate tendon sufficiently to achieve a biomechanically-competent repair clearly causes ischaemia in itself, thus promoting the tendon problem. Use of a single point of contact (even in a multi-stranded anchorage) does not make sense across an area of deficiency. Consequently, several methods of fixation of the torn tendon have been developed and include single- or double-row, and using simple, mattress or complex suture tech-

niques. Debate has ranged across the techniques with strong advocates for each: no technique appears to address the bone surface or how this affects the capacity of the enthesis to heal. Anchors of different materials, sizes, in vitro behaviour and ease of handling confuse the issue; simple transosseous suture techniques were effective when open surgery for rotator cuff was practiced. To the debate on the management of partial thickness tears is added the treatment of the retracted posterosuperior rotator cuff tear in patients for whom tendon transfer or reverse shoulder arthroplasty is undesirable or not indicated. ‘Superior capsule reconstruction’ is the new boy on the block. Where the retracted tendon cannot be brought to the greater tuberosity without undue tension, and there is superior instability of the humerus, closure of the superior capsule by transfer of the rotator interval capsule, intracuff tendon transfer, or transfer of the tendon of the long head of the biceps has long been practiced in open cuff surgery. The arthroscopic technique of superior capsular reconstruction is simply the substitution and/or augmentation of the existing rotator cuff tissue by an interposed patch of synthetic material, allograft or xenograft. Restoration of the mechanical competence of the rotator cuff depends on the reconstruction of the fibrous framework of the rotator cuff mechanism: the ‘fibrous lock’ of Gagey. This consists of the strong fibres of the anterior band of the supraspinatus tendon and the superior border of the subscapularis interacting with the transverse intracapsular cable. Any patch is biomechanically passive and therefore can only work if it affects the function of the fibrous lock system; the literature does not appear to address this concept.

Controversy 4: Instability YouTube is a powerful tool: one of the most common surgical ‘hits’ is the elegant operation performed by the foremost of French shoulder surgeons, Gilles Walch - his Latarjet procedure for recurrent anterior structural instability. Deceptively quick and apparently easy, this has become the treatment of choice for recurrent instability, particularly after failed surgery. It is becoming one of the most chosen options in some centres for first-time dislocation, particularly if the patient is engaged in high-level sport. Conversion into an arthroscopic procedure was inevitable, and there are now advocates and exponents of the several arthroscopic options of the transfer of the coracoid to the anterior glenoid. The operation works either by obstructing

the translation of the humeral head, by supporting it through a greater arc of surface contact (by increasing the arc of stability), or by a ‘dynamic’ check rein effect through the tensioning of the inferior subscapularis muscle fibres by the (taut) coracobrachialis muscle. If a muscle origin (the coracoid) is transferred towards its insertion, it will lose power. Coracobrachialis is innervated by branches of the musculocutaneous nerve of which at least one crosses the upper part of the interval between pectoralis minor and coracobrachialis, and will inevitably be divided during mobilisation of the coracoid; the muscle will therefore be partially denervated and mechanically insufficient for two anatomical reasons. That it works in many is not in question, but the mechanism of action remains controversial. There has to be concern about the effect on the shoulder of a young person who has a non-anatomical procedure in which the muscle which contributes considerably to anterior stability, subscapularis, is damaged, the neuroanatomy of the front of the shoulder disturbed, the capsule only partly reconstructed (in the classic operation), and in which union of the bone block is often incomplete, with broken or displaced metalwork. This is an operation which, when successful, provides the sportsperson with a relatively reliable shoulder, although apprehension is still reported, but which, when attended by complications, becomes a reconstruction challenge and a great problem for the patient. Post-capsulorrhaphy arthropathy may require shoulder arthroplasty at a young age. The incidence of arthritis after recurrent instability is roughly similar to that following all types of anatomical reconstruction, but is increased after non-anatomical procedures. We should be careful about adopting the Latarjet and its derivatives as the primary treatment for anterior glenohumeral instability.

Controversy 5: The reverse shoulder arthroplasty Reverse total shoulder arthroplasty (R-TSA) has captured the hearts and minds of shoulder surgeons. Not surprisingly there are several dozen varieties. They share similar features of being expensive and difficult to perform accurately, and yet are being adopted for increasingly diverse indications. We should ask ourselves why this is. In Japan, where R-TSA was not permitted until well after the wholesale adoption of the method in Europe and North America, small humeral head replacement and subscapularis transfer with latissimus dorsi transfer generated outcomes at least as good as those of R-TSA.

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That good outcomes of latter-generation R-TSA are being reported after short-term review is not debated, but these reports were for selected cohorts of patients with the specific diagnosis of cuff tear arthropathy according to Hamada. Is the rotator cuff deficient osteoarthritic shoulder the same as a cuff tear arthropathic shoulder? In terms of pathology, clearly not, but in biomechanical terms they are similar. The outcome of the former after R-TSA might be better because it may be possible to repair the rotator cuff around the prosthesis — that is, create a rotator cuff sufficient shoulder around a R-TSA. If that were possible, why not recreate a cuff sufficient shoulder around an anatomical TSA, which would give a reliable restoration of normal kinematics, and, should revision be necessary, one that is easier to undertake, particularly if a short-stemmed TSA using the latest generation of metal-backed glenoid components is used initially. When a R-TSA requires revision, the challenge of bone loss is substantial and often greater than that seen when an anatomical TSA has been used. The rapid uptake of R-TSA, as evidenced by the UK National Joint Registry, may herald a wave of revisions in a few years with bone loss and deltoid insufficiency as the hallmarks of a difficult clinical situation. Whether computer-derived, personalised instrumentation will change this is to be proven. All such derivatives focus on the scapula as a challenge for implantation, but there is scant literature on the relationship between the centroid of rotation of the R-TSA and the deltoid in the axial plane. In particular, explanations of the mechanism of the R-TSA focus on the anterior deltoid (for elevation), rather than the posterior deltoid (for external rotation, a more useful function). There is some way to go before the place of R-TSA in the surgeons’ armamentarium is clear, and whether all shoulder surgeons should undertake this procedure. R-TSA is fast becoming the treatment of choice for complex fractures of the proximal humerus in the elderly,

and in younger patients with fractures which are difficult to reconstruct, particularly when the surgeons’ repertoire of soft-tissue reconstruction surgery is incomplete. This trend has to be monitored carefully, particularly in the light of recent evidence of a UK randomisedcontrolled trial of the treatment of proximal humeral fractures.

Controversy 6: The proximal humeral fracture The ProPHER trial has been rightly hailed as a great attempt to define how to treat fractures of the proximal humerus (PHF). It was published in JAMA in 2015, in the same year as the Cochrane Review of the treatment of PHFs, authored in part by one of the authors of the ProPHER trial. The review stated that there was insufficient evidence from existing literature to decide whether operative treatment had any advantage over non-operative treatment for a range of PHFs. It went on to say that there was no clear evidence to recommend one form of operative treatment over another, nor when to start mobilisation after injury or surgery. A total of 1250 patients were entered into the ProPHER trial, of whom only 250 matched the inclusion criteria. Of the 109 who eventually underwent surgery, carried out by 66 surgeons in 30 centres over a two-year period, only five (0.4% of the total, and 4% (5 in 109) of the operated group) were four-part fractures (by Neer criteria). More patients in the operated group than the non-operated group had complications. The primary outcome score was the Oxford Shoulder Score which was originally designed to describe the outcome for pain perception after surgery in a general shoulder outpatient setting. The headline conclusion was that operative intervention in PHFs was no better than non-operative treatment. This headline has been adopted by the general trauma and shoulder surgery community, and allegedly by insurance companies in the US (personal

communication, Dr Keith Mayo), as showing a non-beneficial effect of operative intervention and therefore not supported by those who purchase surgical care. Meanwhile, colleagues in Europe are demonstrating in carefullyconducted cohort and RCT studies that the effectiveness and operative outcome of PHF treatment is dependent on the accuracy of reduction and the ability to maintain that reduction. Other studies have shown that the complication rate after surgical intervention in these fractures is almost wholly surgeondependant, rather than dependent on the implant or even on patient characteristics. One interpretation of the ProPHER trial is that UKbased surgeons are not as good as their counterparts in Europe at gaining accurate fracture reduction or conducting post-operative treatment. Perhaps we should not use the outcome of the trial to deny patients what might actually be the appropriate surgical treatment, but rather train our surgeons to operate better. Given that the average number of PHF interventions per surgeon in the trial appears to be less than two in the two-year trial period, we should perhaps be better at organising appropriate centres for the management of these difficult fractures. Reference 1. Wilhelm A. Die gezielte Schmertzausschaltung am Schultergelenk und ihre anatomischen Grundlagen. Zur Behandlung der schmerzhaften Schultersteife. Langenbecks Arch klin Chir 1963;302:799-809. (In German) A uthor

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Simon Lambert BSc FRCS FRCSEd(Orth), Consultant Orthopaedic Surgeon, Shoulder & Elbow Surgery, Spire Bushey Hospital, Hertfordshire, UK. simonlambert@me.com

BJJN00000029 research-article2016

BJJ News | I ssue 11 | D ecember 2016

CURRENT CONCEPTS

The London Implant Retrieval Centre: what has it done and is retrieval analysis worthwhile?

he London Implant Retrieval Centre (LIRC) has been investigating metal-on-metal (MOM) bearing hips from the start of the modern hip resurfacing and metal bearing total hip arthroplasty (THA) era. Initially patients were presenting with unexplained groin pain.1,2 This was before blood cobalt and chromium ion measurements and MRI imaging of hip implants became the norm. Our work, along with others, has contributed to allowing this to happen. To date we have collected and stored over 7000 implants safely, identifiably and securely. We have a biobanktype resource for future and ongoing research, with patient consent given for all components. Retrievals had previously been collected by engineers who seemed satisfied that the components had been implanted in patients. This seemed insufficient to us as surgeons who wanted to study retrieved implants. Our strategy was to review pre- and post-operative imaging to assess the indication for, and the subsequent performance of, surgery. We then collated MRI and cross-sectional imaging of the biological response, and combined blood tests and clinical data to assess patient characteristics, function and performance.3 It seemed that

because we were also surgeons, colleagues were prepared to forward this information to us, whereas they may have been reluctant to do so with manufacturers. This has optimised clinical retrieval analysis and interpretation. Our engineers have described, refined and published techniques for retrieval analysis.4,5 We have benchmarked our techniques against reference laboratories nationally and internationally, and have undertaken round-robin analysis of implants for validation and quality control. We have been able to define a language and reference system for describing surface changes on metal bearings (lexicon), again by collaborating with engineers globally.6 We were involved in developing metal ion measurement techniques and interpretation from a very early stage. The threshold for concern in unilateral Birmingham hip resurfacing of 7 ppb originated from our unit.7 Whether you love or hate a single value (and 7 ppb as that

value) in a continuous variable, it has become known worldwide, clearly has meaning and indicates that a patient warrants further investigation. We have subsequently worked on assessing the sensitivity and specificity of various blood cobalt and chromium ion concentrations for predicting problems in patients with hip resurfacing and THA prostheses with MOM bearings.8 We have been strong proponents of using metal artifact reduction sequence (MARS) MRI to investigate patients, and have published on the interpretation of MRI findings in assessing hip pain and the effects of age-related macular degeneration (ARMD).9 By 2012 the LIRC, along with colleagues in Newcastle/Stockton-on-Tees and other retrieval centres, had published research showing problems with large diameter metal-on-metal THA.10,11 These were clearly worse than the outcomes of hip resurfacing and it subsequently became clear that this was the worst performing group of hip replacements. However, the regulators did not have enough evidence to act at the time. We therefore tabled a motion on behalf of the LIRC and all UK implant retrieval centres at the annual general meeting of the British Hip Society (BHS), stating that large diameter MOM hip arthroplasties should no

J. A. Skinner H. S. Hothi J. Henckel A. J. Hart

longer be performed, except in an ethicallyapproved clinical trial setting. This was passed unanimously and the BHS issued a press statement to this effect. This soon resonated around the world and the practice was stopped; a clear example of British surgeons, engineers and researchers leading the world in this field and acting to improve patient management. The next topic that arose was the source of debris. In THA with metal bearings, the source was often the taper junction rather than the bearing itself (Fig. 1).5,12 This field expands because although much rarer, taper junction problems have been reported with metal-on-polyethylene bearings. This makes this line of research potentially applicable to 10 million patients worldwide, who have a metal trunnion and a metal femoral head (Figs 2 and 3), but not MOM bearings.13 Our work with metal artefact suppression MRI scans and their interpretation has involved collaboration with radiologists and physicists to devise better MARS sequences.14-16 This work won awards at the Radiological Society of North America in both 2010 and 2012. High quality MARS MRI imaging is now available in most units: good imaging clearly improves patient care. The ability to plan surgery and accurately assess damage pre-operatively,

Fig. 1 The volume of material lost from the female taper surface of a femoral head can be calculated using a roundness measuring machine which takes over a million data points using a 5-micron diamond probe.

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Fig. 2 Image of a retrieved femoral head being examined under an optical profilometer. including intra-pelvic disease, improves outcome by predicting the need for constrained cups, cup cages and abductor reconstruction, for example, and minimises the need for further or staged surgery.17 One of the theoretical concerns with cobaltchromium alloy bearings has always been the potential production of chromium VI ions, a known carcinogen. We have collaborated with the Diamond Light Source team at the National Synchrotron science facility (Didcot, Oxfordshire) since 2010, and have been awarded beam time annually on this £500 million machine.18 This has always been exciting for two orthopaedic surgeons from North London! Our work with this invaluable resource has allowed speciation of metal ions seen in periprosthetic tissue in hip resurfacing, large and small diameter THA and taper problems with non-MOM bearings. The predominant species of chromium III phosphate and chromium III oxide are reassuring. A large, well-documented UK retrieval collection collected over the inaugural ten years of the National Joint Registry (NJR) offers the potential for collaboration and detailed data quality validation. One thing that retrieval centres can guarantee is evidence of both a primary operation and a revision procedure having taken place. This is Level V Registry data, and the NJR remains the only worldwide register to provide it. Linking LIRC data with the NJR allowed a highquality data audit of the NJR. Some data was missing early on but the NJR data becomes increasingly comprehensive and more complete year by year.19 We have shown that data recorded in the NJR is very accurate, but the missing data means that surgeon-level reporting of outcomes for revisions will not be sensible for a long time, if ever.20,21

Fig. 3 We use a coordinate measuring machine to determine the volume of material lost from the cup and head bearing surfaces of retrieved hips. These capture over 30 000 unique data points using a 2 mm ruby stylus.

Fig. 4 The London Implant Retrieval Centre is the independent worldwide retrieval centre for analysis of the recalled Stryker Rejuvenate and ABGII dual-taper implants. As surgeons and clinically-driven engineers, the optimisation of patient management has always been important. We have developed multi-disciplinary team (MDT) working protocols that we use to steer clinical management decisions. We have performed a multicentre analysis of MDT decision-making, to validate and compare management decisions with some of the best orthopaedic units in the world. These have included the Wrightington; Wigan; Hospital for Special Surgery, New York; Coxa, Tampere, Finland; the Endoklinik, Hamburg, Germany and Harvard, Massachusetts.22 We collaborated with cardiologists in response to concerns of case reports of patients with metal-bearing hips developing cardiac failure and a small series of elderly Australian veterans being reported with heart failure. We performed a study of cardiac function in patients with metal-bearing hips and a range of blood metal ion concentrations. The assessment methods included cardiac MRI, echocardiogram

(ECG) and blood test markers of cardiac function. The results were reassuring. To summarise, our strategy has always been focussed on collaboration, working with experts in whichever field we felt the need to explore. We have published with over 200 co-authors worldwide, received implants from more than 110 hospitals in the UK and over 500 contributors from 27 countries worldwide. We have published more than 80 papers which have been cited on over 1000 occasions. Independence has always been important from the time of our initial research when we attracted funding from nine manufacturers via the Association of British Healthcare Industries (ABHI). This funded research, but also gave us full freedom to publish findings without fear or favour. It also allowed us to become, after competitive tender, a retrieval centre for the DePuy (Warsaw, Indiana) ASR and Stryker (Kalamazoo, Michigan) Rejuvenate and ABG II modular neck hip worldwide recalls (Fig. 4).

BJJ News | I ssue 11 | D ecember 2016 16. Berber R, Khoo M, Cook E, et al. Muscle atrophy and metal-on-metal hip implants: a serial MRI study of 74 hips. Acta Orthop 2015;86:351-357. 17. Krishnan H, Magnussen A, Sharma A, Skinner J. Metal on metal total hip arthroplasty and a large groin mass: not always adverse reaction to metallic debris. Int J Surg Case Rep 2015;6C:141-145. 18. Hart AJ, Quinn PD, Sampson B, et al. The chemical form of metallic debris in tissues surrounding metal-on-metal hips with unexplained failure. Acta Biomater 2010;6:4439-4446. 19. Sabah SA, Henckel J, Cook E, et al. Validation of primary metal-on-metal hip arthro-

Fig. 5 All of our implants are anonymised and securely stored in locked cabinets in a locked room. Each implant is assigned a unique identifying barcode and components are scanned in and out of our system when they are moved. Patient education, support and explanation have always been central to our philosophy of patient-centred retrieval analysis. We run frequent open days for patients and have a vibrant ’Friends of the LIRC’ patient group. At such events, hundreds of patients have been able to see their explanted components, understand their wear analysis and meet other patients with similar experiences (Fig. 5). Supporting patients, their legal teams and manufacturers in handling ongoing litigation has also been a major part of our work, which we have now presented in 18 countries to disseminate our findings. Our latest work is using similar advanced measurement methodologies to investigate knee arthroplasty prostheses and spinal implants.

7. Hart AJ, Skinner JA, Winship P, et al. Circulating levels of cobalt and chromium from metal-on-metal hip replacement are associated with CD8+ T-cell lymphopenia. J Bone Joint Surg [Br] 2009;91-B:835-842. 8. Hart AJ, Sabah SA, Bandi AS, et al. Sensitivity and specificity of blood cobalt and chromium metal ions for predicting failure of metalon-metal hip replacement. J Bone Joint Surg [Br] 2011;93-B:1308-1313. 9. Matthies AK, Skinner JA, Osmani H, Henckel J, Hart AJ. Pseudotumors are common in well-positioned low-wearing metal-on-metal hips. Clin Orthop Relat Res 2012;470:1895-1906. 10. Hart AJ, Muirhead-Allwood S, Porter M, et al. Which factors determine the wear rate of

plasties on the National Joint Registry for England, Wales and Northern Ireland using data from the London Implant Retrieval Centre: a study using the NJR dataset. Bone Joint J 2015;97-B:10-18. 20. Sabah SA, Henckel J, Koutsouris S, et al. Are all metal-on-metal hip revision operations contributing to the National Joint Registry implant survival curves?: a study comparing the London Implant Retrieval Centre and National Joint Registry datasets. Bone Joint J 2016;98-B:33-39. 21. Haddad FS, Manktelow AR, Skinner JA. Publication of surgeon level data from registers: who benefits? Bone Joint J 2016;98-B:1-2. 22. Berber R, Skinner J, Board T, et al; ISCCoMH. International metal-on-metal multidisciplinary teams: do we manage patients with metal-on-metal hip arthroplasty in the same way? An analysis from the International Specialist Centre Collaboration on MOM Hips (ISCCoMH). Bone Joint J 2016;98-B:179-186.

large-diameter metal-on-metal hip replacements? References

Multivariate analysis of two hundred and seventy-six

1. Hart AJ, Sabah S, Henckel J, et al. The pain-

components. J Bone Joint Surg [Am] 2013;95-A:678-685.

ful metal-on-metal hip resurfacing. J Bone Joint Surg

11. Langton DJ, Jameson SS, Joyce TJ, et al.

[Br] 2009;91-B:738-744. .

Early failure of metal-on-metal bearings in hip resur-

2. Hart AJ, Hester T, Sinclair K, et al. The asso-

facing and large-diameter total hip replacement: a

ciation between metal ions from hip resurfacing and

consequence of excess wear. J Bone Joint Surg [Br]

reduced T-cell counts. Bone Joint J [Br] 88-B: 449-454.

2010;92-B:38-46.

3. Hart AJ, Satchithananda K, Liddle AD,

12. Langton DJ, Sidaginamale R, Lord JK,

et al. Pseudotumors in association with well-

Nargol AVF, Joyce TJ. Taper junction failure in

functioning metal-on-metal hip prostheses: a case-

large-diameter metal-on-metal bearings. Bone Joint

control study using three-dimensional computed

Res 2012;1:56-63.

tomography and magnetic resonance imaging.

13. Hothi H, Kendoff D, Lausmann C, et al.

J Bone Joint Surg [Am] 2012;94-A:317-325.

Clinically insignificant trunnionosis in large diam-

4. Bills PJ, Racasan R, Underwood RJ, et al.

eter metalon-polyethylene total hip replacements.

Volumetric wear assessment of retrieved metal-on-

Bone Joint Res 2016; 5: in press.

metal hip prostheses and the impact of measure-

14. Sabah SA, Mitchell AW, Henckel J, et al.

ment uncertainty. Wear 2012;274:212-219.

Magnetic resonance imaging findings in pain-

5. Matthies AK, Racasan R, Bills P, et al.

ful metal-on-metal hips: a prospective study.

Material loss at the taper junction of retrieved

J Arthroplasty 2011;26:71-76, 76.e1-76.e2.

large head metal-on-metal total hip replacements.

15. Siddiqui IA, Sabah SA, Satchithananda

J Orthop Res 2013;31:1677-1685.

K, et al. A comparison of the diagnostic accu-

6. McKellop HA, Hart A, Park SH, et al. A

racy of MARS MRI and ultrasound of the pain-

lexicon for wear of metal-on-metal hip prostheses. J

ful metal-on-metal hip arthroplasty. Acta Orthop

Orthop Res 2014;32:1221-1233.

2014;85:375-382.

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J.A. Skinner, MBBS, FRCS (Eng), FRCS (Orth) London Implant Retrieval Centre, University College London and the Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK H.S. Hothi, BEng, MSc, PhD London Implant Retrieval Centre, University College London and the Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK J. Henckel, MRCS London Implant Retrieval Centre, University College London and the Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK A.J. Hart, FRCSG (Orth), MD London Implant Retrieval Centre, University College London and the Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK john.skinner@ucl.ac.uk

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CURRENT CONCEPTS

Current state of robotics in knee surgery

The original orthopaedic robots Computer numerical control (CNC) machines are now ubiquitous in manufacturing for cutting, milling, drilling and routing of almost any material; their accuracy is far better than manual machining, while their speed and reliability have driven their widespread adoption across all manufacturing industries. Translating this robotic technique into arthroplasty surgery has obvious appeal, with a similar desire for accuracy and a suitably rigid substrate in bone combined with the industrial quantities of joint arthroplasties needing to be undertaken. In the 1980s these CNC machines inspired the first attempts to develop fully active orthopaedic robots based on existing industrial machines. Once fixed in position, these robots autonomously machined bone without the need for surgical control, hence the label ‘active robots’. The first human procedure, that of milling the femoral canal for a femoral hip prosthesis, was performed using the ROBODOC system, the result of collaboration between IBM Research and the University of California, Davis.1 A total knee arthroplasty (TKA) module soon followed for both ROBODOC and its rival German system CASPAR (Orto Maquet; Rastatt, BadenWürttemberg, Germany). The operating time taken and lack of clinical benefit prevented their adoption. Concerns over loss of control led to the development in our institution of a ‘semi-active’ robot, the Acrobot System (Stanmore Implants, Elstree, UK), the key difference being that the robot moved under servo-assistance in response to input from the surgeon, providing continuous haptic feedback while restricting movement within a pre-defined margin of bone resection. The Acrobot was developed with unicondylar knee arthroplasty (UKA) in mind,2 but was initially trialled in TKA surgery.3

Orthopaedic robots now Although both fully active and semi-active robots aligned prostheses accurately in both invitro and in-vivo studies,2,4 uptake was limited because of the significant upfront costs (ROBODOC in the 1990s cost between US$635 000 and $1.5 million5); large unwieldy machines,

and increased operating times were among other reasons. However, this first-generation technology introduced the concept of 3D preoperative planning and formed the basis for the second generation of interest and development we are seeing currently in this sector, as evidenced by the purchase of Mako Surgical Corporation (Fort Lauderdale, Florida) by Stryker in 2013, and more recently Smith & Nephew’s 2015 acquisition of Bluebelt. The Mako RIO is a semi-active robot which uses a 3D, CT-based pre-operative plan to carry out UKA, patello-femoral joint arthroplasty (PFJA), and the acetabular component during total hip arthroplasty (THA), with TKA to follow shortly.6 In the same way as the Acrobot System, the surgeon controls a robotic burr within a pre-defined margin of bone resection. But like the Acrobot’s successor, Sculptor (subsequently purchased by Mako; now owned by Stryker; Kalamazoo, Michigan), this second generation robot overcomes the need to rigidly secure the patient’s leg to the robot by employing an optical tracking system. The advantage of a controlled burr over a system which positions a surgical guide for use with traditional saws is, in theory, less risk for soft-tissue damage, although this is dependent on accurate registration. Each Mako Rio is apparently sold for US$1 million. The Navio system (Bluebelt Technologies, Smith & Nephew, Andover, Massachusetts) is a handheld tool which also houses a high speed burr. This is not attached to a robot arm, and represents a different approach to the concept of active constraint first seen in the Acrobot System; instead of limiting hand motion outside a pre-defined area, the tool can be moved freely, but the rotating cutter retracts when it drifts outside of the area planned for bone resection.7 This technology is available for UKA and PFJA surgery, and is currently based on image-free intra-operative navigation, the surgeon defining the operative field as it proceeds. The cost of each machine has been estimated to be approximately half that of the Mako Rio. Aside from the Navio and Rio, the latest evolution of ROBODOC, called TCAT, (Think Surgical, Fremont, California) was released in 2014. There are also a number of smaller companies

G. G. Jones J. P. Cobb

developing miniaturised bone-mounted robots; those which function to position a cutting guide (termed ‘passive robots’ because they do not perform bone resection) such as Praxiteles,8 and those which carry out the machining, e.g. MBARS.9 To be widely adopted, robots need to make a compelling case based upon utility. Industrial robots are faster, cheaper and more reliable than humans, while arthroplasty robots are currently slower and more expensive. The upfront cost of a clinical robot remains significant, as do the maintenance and upgrade costs. The reduced theatre efficiency due to longer operating times is hard to manage in any environment where there is pressure on operating theatre time. There are potential efficiencies: improved accuracy should theoretically deliver better patient outcomes, with fewer short-term complications and reduced long-term revision rates.6 There is the potential to reduce equipment and sterilisation costs for each case, and a CT- or MRI-based plan facilitates a move towards a ‘just-in-time’ manufacturing model, with financial savings through reduced hospital implant inventories. In environments where healthcare is competitive, robots may attract patients to a clinic, so the purchase cost can be borne by the marketing department rather than coming from the theatre budget. This appears to be a strong factor in play today.

Additive layer manufacturing Echoing the relationship between CNC machines and orthopaedic robots, the more recent invention and adoption of additive manufacturing (3D printing) in industry has led to its translation to orthopaedic surgery in the form of 3D-printed guides, also known as patient-specific instrumentation (PSI). This technology can be considered equivalent to passive robots, in that the aim is to position a cutting guide accurately through which the surgeon performs a saw cut. Such 3D-printed guides have the potential to offer two of the main advantages associated with robots: a 3D pre-operative plan (CT- or MRI-based) and improved accuracy. This is supported by a study we conducted comparing a

BJJ News | I ssue 11 | D ecember 2016

first generation PSI (Embody, London, UK) with Sculptor, a second generation semi-active robot (Stryker; Kalamazoo, Michigan), and conventional instruments, to perform a UKA in a sawbone model.10 The robot and PSI guides were both better than conventional guides in accurately delivering the pre-operative plan. The only difference in accuracy between the two technologies was marginally improved tibial rotational alignment with the robot. Importantly, the time taken to complete the procedure with the Sculptor was more than double that of the PSI and conventional instruments. So PSI has the potential to deliver robot-level accuracy, combined with improved operating theatre efficiency, and the reduction in inventory that comes with detailed planning. Clinical studies have so far given contradictory results as to whether PSI is more accurate than conventional guides. A recent randomised controlled study of medial UKA showed no difference in component positioning or functional outcomes between operations performed by expert surgeons using conventional instruments and PSI.11 While the authors expressed their disappointment, they have demonstrated that PSI reliably replicates the radiological results of expert surgeons.12 Further studies are needed to test this hypothesis in less experienced hands. PSI is attractive economically, with each guide costing a few hundred euros.13 This cost should fall with the cost of 3D printers and improved automation. Operating equipment and sterilisation costs are reduced, particularly if the guides incorporate cutting slots. As with robots, a pre-operative 3D plan permits implant inventory savings by determining the size of device needed for each case. Theatre efficiency can also be improved. At current prices (including the price of an MRI or CT scan), the use of PSI has been estimated as cost neutral due to these savings.

Why do we need this technology in knee arthroplasty? The benefit delivered by assistive technology in the field of arthroplasty remains uncertain. In part this is due to the insensitivity of current outcome measures; the bluntest of these, revision rate, is difficult to assess due to the long-term nature of such studies and the requirement for large patient numbers. Additionally, current patient reported outcome measures (PROMs) are associated with significant ceiling effects14 which is why our group, jointPRO (www.jointpro.co.uk) and others15

are developing questionnaires which are better able to capture the upside of a procedure. A move toward objective outcome measures such as gait characteristics may also help answer how much influence operative accuracy has on outcome.16

References

The strongest argument for this technology at present is in conservative surgery of both the hip and knee. UKA is an operation associated with better kinematics than TKA17 with a lower mortality, length of stay and fewer complications.18 However, the higher revision rate seen in low-volume surgeons means that it only accounts for 9% of knee arthroplasties in the UK.19 This revision rate is at least in part attributable to malalignment and improper soft-tissue balancing. It is encouraging that a conference presentation of a multicentre study using a robot had a significant lower revision rate compared to registries, even at only two years follow-up.20 Perhaps assistive technology could enable more widespread adoption of technically demanding procedures such as UKA and hip resurfacing.

robotic

1. Paul HA, Bargar WL, Mittlestadt B, et al. Development of a surgical robot for cementless total hip arthroplasty. Clin Orthop Relat Res 1992;285:57-66. 2. Cobb J, Henckel J, Gomes P, et al. Hands-on a

unicompartmental

prospective,

knee

randomised

replacement:

controlled

study

of the acrobot system. J Bone Joint Surg [Br] 2006;88-B:188-197. 3. Jakopec M, Harris SJ, Rodriguez y, Baena F, et al. The first clinical application of a “hands-on” robotic knee surgery system. Comput Aided Surg 2001;6:329-339. 4. Park SE, Lee CT. Comparison of roboticassisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty 2007;22:1054-1059. 5. Bargar WL. Robots in orthopaedic surgery: past, present, and future. Clin Orthop Relat Res 2007;463:31-36. 6. Conditt M, Coon T, Roche M, et al. Two year survivorship of robotically guided unicompartmental knee arthroplasty. Orthopaedic Proceedings

Conclusion

2013;95-B(Suppl):294.

Technology which improves the accuracy of an operation is a positive influence on the world of arthroplasty. However, any candidate technology must also present a compelling economic argument before it is adopted. Navigation systems, not discussed in this article, are another competing technology in this sector. They have their advocates, but have not made it to the mainstream owing to a lack of compelling evidence of a clinical benefit that outweighs the cost in terms of time. The upfront financial costs for robots remain high. While robots may be highly cost-effective, for instance in the manufacturing process of femoral stems, they are some way from proving their cost effectiveness in the operating theatre. In general it is probably good advice to wait for any technology to mature before recommending its widespread adoption. At present the case for PSI is more compelling economically – surgeons and their hospitals can obtain experience with the technology without spending US$1m. External pressures will probably determine which of these candidate technologies emerges as the winner. Uber has now replaced the experience of the licensed cab driver. Driverless cars will replace them soon. The explosion of virtual and augmented reality headsets into the retail space heralds the introduction of another dimension. Every one of these technologies may be rendered redundant shortly. Watch this space!

7. Jaramaz B, Nikou C. Precision freehand sculpting for unicondylar knee replacement: design and experimental validation. Biomed Tech (Berl) 2012;57:293-299. 8. Plaskos C, Cinquin P, Lavallée S, Hodgson AJ. Praxiteles: a miniature bone-mounted robot for minimal access total knee arthroplasty. Int J Med Robot 2005;1:67-79. 9. Wolf A, Jaramaz B, Lisien B, DiGioia AM. MBARS: mini bone-attached robotic system for joint arthroplasty. Int J Med Robot 2005;1:101-121. 10. Jaffry Z, Masjedi M, Clarke S, et al. Unicompartmental vs.

patient

knee

specific

arthroplasties:

robot

instrumentation.

Knee

2014;21:428-434. 11. Ollivier M, Parratte S, Lunebourg A, Viehweger E, Argenson JN. The John Insall Award. No functional benefit after unicompartmental knee arthroplasty performed with patientspecific instrumentation: a randomized trial. Clin Orthop Relat Res 2016;474:60-68. 12. Logishetty K, Jones GG, Cobb JP. Letter to the Editor: The John Insall Award: no functional benefit after unicompartmental knee arthroplasty performed

with

patient-specific

instrumenta-

tion: a randomized trial. Clin Orthop Relat Res 2016;474:272-3. 13. Tibesku CO, Hofer P, Portegies W, Ruys CJM, Fennema P. Benefits of using customized instrumentation in total knee arthroplasty: results from an activity-based costing model. Arch Orthop Trauma Surg 2013;133:405-411.

BJJ News | I ssue 11 | D ecember 2016 14. Jenny JY, Louis P, Diesinger Y. High activ-

18. Liddle AD, Judge A, Pandit H, Murray

arthroplasty. http://www.bjjprocs.boneandjoint.org.

ity arthroplasty score has a lower ceiling effect

DW. Adverse outcomes after total and unicom-

uk/content/95-B/SUPP_34/294 (date last accessed

than standard scores after knee arthroplasty. J

partmental knee replacement in 101,330 matched

11 October 2016).

Arthroplasty 2014;29:719-721.

patients: a study of data from the National

15. Noble PC, Scuderi GR, Brekke AC, et al.

Joint Registry for England and Wales. Lancet

Development of a new Knee Society scoring sys-

2014;384:1437-1445.

tem. Clin Orthop Relat Res 2012;470:20-32.

19. No authors listed. National Joint Registry

16. Wiik AV, Manning V, Strachan RK, Amis AA,

12th

Cobb JP. Unicompartmental knee arthroplasty enables

uk/njrcentre/Portals/0/Documents/England/

near normal gait at higher speeds, unlike total knee

Reports/12th%20annual%20report/NJR%20

arthroplasty. J Arthroplasty 2013;28(9 suppl):176-178.

Online%20Annual%20Report%202015.pdf

17. Chassin EP, Mikosz RP, Andriacchi TP,

last accessed 10 October 2016): 81-88.

Rosenberg AG. Functional analysis of cemented

20. Coon T, Roche M, Pearle A, Dounchis J,

medial unicompartmental knee arthroplasty. J

Borus T, Buechel F, Jr. Two year survivorship

Arthroplasty 1996;11:553-559.

of robotically guided unicompartmental knee

annual

report

http://www.njrcentre.org.

FORTHCOMING

Orthopaedic Meetings CPD ACCREDITED

(date

A uthor

details

Gareth G. Jones, Honorary Clinical Research Fellow, Imperial College London, London, UK ggjones@imperial.ac.uk Justin P. Cobb, Chair in Orthopaedic Surgery, Imperial College London, London, UK

Birmingham Patellofemoral Masterclass 28th & 29th October 2016 QEII Hospital, Birmingham

www.birminghampatfem.org

10 CPD POINTS

Bristol / Oxford Unicompartmental Knee Arthritis Meeting 15th November 2016 Ashton Gate Stadium, Bristol

www.unikneemeeting.org

6 CPD POINTS

Bristol Hip Arthroplasty Course 10th & 11th November 2016 City Centre Marriott, Bristol

www.bristolhip.org

11 CPD POINTS

Basingstoke Knee Osteotomy Masterclass 1st & 2nd December 2016 The Ark Centre, Basingstoke

www.basingstokeknee.org

11 CPD POINTS

Orthopaedic Trauma Society Annual Meeting 12th & 13th January 2017

Organised by

Scarman Hse, Univ of Warwick Tel: 01476 860759 | bookings@clockwork-uk.com

9 CPD POINTS

www.meeting.orthopaedictrauma.org.uk

BJJN00000024 research-article2016

BJJ News | I ssue 11 | D ecember 2016

N. V. Todd

CURRENT CONCEPTS

Changing the operating surgeon: specific consent required

n these target-driven days, patients who have been workedup and put onto a waiting list by one surgeon are often transferred to – and have the operation performed by – another surgeon, in the same or another Trust or in the private sector. In a recent case involving spinal surgery a patient became aware, immediately pre-operatively, that a different surgeon would be carrying out the operation, she underwent decompressive surgery with catastrophic results.1

The defendant Trust was found to be in breach of duty of care because consent to be operated upon by the new surgeon “was not freely taken”.1 The judgement has implications for all surgeons.

History Mrs Jones had low back pain and bilateral neurogenic lower limb claudication. MR imaging had demonstrated central and bilateral stenosis at L4/5. Mrs Jones had an epidural injection with no benefit. She then saw Mr A (consultant orthopaedic spinal surgeon) who offered her bilateral L4/5 decompressions. There was evidence that he had an excellent reputation locally and nationally and Mrs Jones wanted him to carry out the operation, to the extent that she deferred surgery on one occasion when Mr A unexpectedly took compassionate leave for a few weeks. Mrs Jones’ care was transferred to Mr B (a fully trained spinal surgeon awaiting his first consultant appointment), without Mrs Jones’ knowledge. Mr B and Mrs Jones first met six days prior to surgery in a pre-admission clinic where a consent form was signed. Mr B said that, in out-patients, he told Mrs Jones that he would be the operating surgeon. Mrs Jones disputed this, saying that she assumed that Mr B was one of Mr A’s assistants and that Mr A would be carrying out the operation. Mrs Jones said that she only became aware that Mr B was to be the operating spinal surgeon on the ward just prior to being taken to Theatre, by which time she “felt as if I was beyond the point of no return”.1 During the operation there was a dural tear with prolapse of nerve roots and

vulsion of at least one nerve root. Mrs Jones a was left with long-term severe deficits including bladder and bowel dysfunction, sensory losses, weakness and balance disturbance causing major functional deficits.

Judgement David Blunt QC (Recorder) found that Mrs Jones learned that Mr A was not going to perform the procedure as she was about to go to theatre. This deprived her of the opportunity to consider, and object to, the change of surgeon. Consent to the change of surgeon was not freely given and this was a breach of the duty of care. Causation was considered on two bases: 1. The risk of a dural tear/cauda equina injury would have been less in the more experienced hands of Mr A; 2. That respect must be “given to the autonomy and dignity of the patient”.1

Discussion In order to succeed in a claim in clinical negligence, the claimant must establish that there was a duty of care which was breached and the breach caused harm. Informed consent is a specific duty of care. Duties of care in relation to consent have recently been clarified.2 Briefly: doctors cannot act in an authoritarian manner telling patients what is to be done; autonomy demands that patients must understand the nature of the proposed treatment, its benefits, risks and any alternatives to the proposed treatment; the risks are specific to the case; all relevant matters must be put in front of the patient, the patient is not required to ask relevant questions; the knowledge is that which would be needed for the average patient to decide whether, or not, to have the operation; the surgeon must be sure that the patient has understood the information.2,3 For elective procedures there must be a ‘cooling-off’ period to allow the patient to reflect upon the issues. In this case,1 the issue was whether the treating surgeon is a relevant issue in relation to

consent to a routine, elective spinal operation. The duty to warn was addressed by Lord Hope in Chester v Afshar:4 “I start with the proposition that the law which imposed the duty to warn on the doctor has at its heart the right of the patient to make an informed choice as to whether, and if so which and by whom, to be operated on” (author’s emphasis). In other words, the patient has the right to decide who the treating surgeon should be. GMC Guidance5 states, “. . . doctors should do their best to find out about patients’ individual needs and priorities when providing information about treatment options. It advises that discussions should focus on the patient’s individual situation and risk to them. . . If a person is not asked to signify their consent until just before the procedure is due to start, at a time when they may be feeling particularly vulnerable, there may be real doubt as to its validity”. The individual situation in Mrs Jones’ case was that she wished to be operated upon by Mr A. She was effectively being asked to agree to a change of surgeon at the doors of the theatre with no ‘cooling-off’ period of reflection, and this did not amount to informed consent to the change of surgeon. Six days prior to surgery Mrs Jones signed a consent form which stated, “I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience”. Despite this, the Court found that the Trust was in breach of duty of care in failing to provide the surgeon that Mrs Jones had understood would be performing the operatation. Clearly the important issue is what the patient has been told, understands and expects and not what is printed on a form.

BJJ News | I ssue 11 | D ecember 2016

In considering causation, the judge quoted Lord Bingham in Chester v Afshar:4 “If the evidence had entitled the judge to conclude and if he had concluded, that Miss Chester, if properly warned as she should have been, could and would have minimised the risk of surgery by entrusting herself to a different surgeon, or undergoing a different form of surgery, or (in another kind of case) losing weight or giving up smoking. . . .” In this case the judge found that the risk of injury to the dura and cauda equina nerve roots would have been less if Mr A had been the surgeon. However even if that was not the case, causation could still be established: “The function of the law is to enable rights to be vindicated and to provide remedies when duties have been breached. Unless this is done the duty is a hollow one, stripped of all practical force and devoid of all content. It will have lost its ability to protect the patient and thus to fulfil the only purpose which brought it into existence. On policy grounds therefore I would hold that the test of causation is satisfied in this case. The injury was intimately involved with the duty to warn. The duty was owed by the doctor who performed the surgery that Miss Chester consented to. It was the product of the very risk that she should have been warned

about when she gave consent. So I would hold that it can be regarded as having been caused, in the legal sense, by breach of that duty”.4

However it is important for us to recognise that this is now legally mandated. References 1. No authors cited. Kathleen Jones v Royal

Patient autonomy, human rights and public policy led to the conclusion that if there is a breach of duty of care in relation to consent, even if classical ‘but-for’ causation cannot be established (the lower risk argument set out above), causation can, legally, be assumed. This judgment has important implications for all surgeons. This is particularly so now, when Trusts believe that patients on a waiting list are ‘Trust’ patients, not patients specific to a treating consultant. Although not specified in the judgment, the following conclusions appear to be inescapable: where a patient has been offered elective surgery by one consultant and has been put onto a waiting list, if the Trust wishes to substitute a different surgeon (usually to achieve a government target), the Trust must inform the patient and the new surgeon must see the patient in outpatients well before the planned surgery (to allow a ‘cooling-off’ period); the reasons for the change of surgeon should be explained and, if the patient agrees, the explanation and the patient’s consent should be recorded in writing. If the patient does not agree they must stay under the care, and on the waiting list, of the original consultant. This no doubt will be no surprise to most surgeons who, if being asked to take over the care of a patient, would meet the patient in outpatients and discuss matters fully with them.

Devon and Exeter NHS Foundation Trust. 22 September

2015.

high-court-justice.vlex.co.uk/

vid/hqx02537-52752128 (date last accessed 20 October 2016). 2. No

authors

Lanarkshire

Health

cited. Board

Montgomery [2015]

UKSC

v 11.

https://www.supremecourt.uk/decided-cases/ docs/UKSC_2013_0136_Judgment.pdf (date last accessed 20 October 2016). 3. Todd NV. Medical negligence. Legal theory and neurosurgical practice: informed consent. Br J Neurosurg 2014;:28:447-451. 4. No authors cited. Chester v Afshar [2004] UKHL 41, [2005]1 AC 134. http://www.bailii.org/ uk/cases/UKHL/2004/41.html (date last accessed 20 October 2016). 5. No authors cited. Department of Health. Reference guide to consent for examination and treatment (second edition). para 31. https://www. gov.uk/government/uploads/system/uploads/ attachment_data/file/138296/dh_103653__1_.pdf (date last accessed 20 October 2016).

A uthor

details

N.V. Todd, Consultant Neurosurgeon and Spinal Surgeon, Newcastle Nuffield Hospital, Newcastle, UK. nick.todd@nicktoddoffice.co.uk

BJJN00000023 research-article2016

BJJ News | I ssue 11 | D ecember 2016

TRAINING

Teaching snapshot: a qualitative and quantitative review of higher orthopaedic teaching programmes in the UK

ittle work has been published on the extent and nature of teaching programmes for trainees in any medical discipline in the UK. Higher orthopaedic training programmes require the delivery of formal education as an adjunct to curriculum delivery as part of the programme. Our aim was to define the current state of play within training programmes in the UK, quantitatively describing the nature of formal teaching and presenting a qualitative account from orthopaedic trainees. Our objective was to define a ‘best practice’ model. The study was run through the British Orthopaedic Trainees Association (BOTA) network of linkmen. ‘Linkmen’ are elected representatives from each deanery whose role is to channel concerns about training or other matters to BOTA. Linkmen were chosen for this project because they were expected to be aware of the general consensus within their deanery regarding their teaching programme. A questionnaire was sent through Survey Monkey to the linkman for each deanery in April 2015 and responses were accepted until July 2015. Data were analysed using Survey Monkey online analysis tools for simple demographics, and the free text responses were collated. Simple analysis was undertaken looking for common themes pertaining to excellence in teaching, and aspects of teaching which trainees found to be suboptimal. There are 29 regional teaching programmes in the UK, and we received responses from 26 (89%) of them. All deaneries surveyed had a training programme director in place, as prescribed by The Gold Guide.1 The linkmen sur-

veyed represented a spread of seniority throughout surgical training grades, ranging from ST3 to ST8. Of the 26 deaneries, 14 (54%) had a separate lead for the education programme, with a role distinct from that of the training programme director. Weekly registrar teaching was carried out in 17 deaneries (58%), five (19%) had teaching between once a week and once a month, two (8%) had teaching once a month and one (4%) had teaching less than once a month. One

deanery (4%) did not hold a teaching programme, instead sending its registrars to neighbouring deaneries for teaching. Teaching attendance is mandated in all deaneries, and trainees must attend a variable proportion of teaching in order to progress through the training programme. Engagement with teaching is assessed at the Annual Review of Competence Progression (ARCP – a panel of senior orthopaedic consultants including the training programme director (TPD) who reviews a trainee’s portfolio from the preceding year and gives permission to progress to the next year of training). The level of attendance to permit satisfactory progression ranges between 70% and 90%. The mean satisfactory compulsory attendance was 74%. Of the 25 deaneries that host a teaching programme, 22 follow the national Joint Committee on Surgical Training (JCST) curriculum for trauma and orthopaedics,2 and three follow a locally-devised curriculum. The teaching programme schedule and locations are usually announced in advance. The timescale for providing trainees with preteaching information such as date, location, topic and expected prior reading was found to be variable. Five deaneries reported that details of teaching were advised with less than six weeks’ notice. This brings into conflict attendance at teaching and the delivery of service as six weeks’ notice is usually required for study leave. Lectures are the most common method of teaching, with two deaneries delivering between 80% and 90% of teaching in this way. Clinical cases were less common, with a maximum proportion of 30% to 40%, and quiz or interactive sessions were the rarest style of teaching, with seven deaneries providing none and ten providing as much as 20% to 30% via this method. Clinical cases (those with patients present) were the method of teaching most preferred by trainees (60%), with 35% expressing a preference for a quiz or interactive modality. Lectures were the least preferred style of teaching with only 8% of trainees stating a liking for them. Themes of satisfaction centred on wellorganised, high-quality consultant-led teaching

J. Shelton S. R. Platt BOTA Linkmen Collaborative

with readily available exam preparation for senior trainees. Cadaveric/prosection anatomy demonstrations were also highly valued but less frequently available across the country. The survey found a single deanery whose trainees rely on access to out-of-deanery training programmes. Areas where teaching was suboptimal focussed on infrequent teaching, poor organisation and a lack of consultant input; one respondent raised concerns around a lack of accessibility and long commutes to teaching. The quality of a teaching programme was only felt to be important in the decision to apply for a higher training post in a certain deanery by 28% (seven respondents). Trainees who had passed the Trauma and Orthopaedics exit exam (FRCS Tr & Orth) regularly attended teaching in 11 (42%) of the deaneries. The teaching and training of trauma and orthopaedics across the UK shows wide variation both in its organisation and delivery. Though trainees value the formal teaching they receive, there is evidence that quality varies across deaneries. Programmes which deliver excellence in teaching are characterised by engagement from trainers, evidence of leadership and organisation, a wide range of teaching modalities centred around the clinical experience and targeted teaching for exam preparation where appropriate. This study shows that trainees perceive highquality teaching as occurring across most training programmes. We have found examples of exemplary teaching practice and suggest these benchmarks are modelled, so as to deliver a uniformly high standard across regions. Programmes without leadership and organisation, where consultant input to the teaching programme is sparse and lacking in educational creativity have been highlighted as areas of concern in instances where trainees found their educational programme to be suboptimal. The foundation of a teaching programme is its administrative organisation. On this foundation may sit excellence in teaching. Maslow considered the hierarchy of needs for learning,3 and the influence on learning environments was described by Roff and Leinster.4 This is well described in educational literature but equally confirmed by the results of our investigation.

BJJ News | I ssue 11 | D ecember 2016

Though this is simply a snapshot of how higher orthopaedic education operates in the UK, it does show that there is a discrepancy between what the trainees want and how it is delivered. What we infer from this survey is that deanery teaching is a highly valued area of a trainee’s education. There was not a single comment stating that too much teaching was delivered. In fact, from the free text responses, it would appear that trainees would like more. Most deaneries have a regular weekly teaching programme. This allows the timely booking of leave. Programmes providing less frequent sessions fall foul of this due to the irregular delivery of teaching sessions, resulting in trainees being unable to arrange leave. There appeared to be an association between having an educational lead and regular weekly or monthly teaching. The absence of a TPD left many trainees without a regular teaching plan. With good logistics the trainer can begin to explore the ‘who am I teaching’ question.5 The answer to this question is on many levels. When one considers this answer in the context of a curriculum, perhaps this is the basis for the development of excellence in a teaching programme. The regional format of most of the teaching sessions is predominantly lecture-based. Our study highlights the fact that trainees prefer clinical and interactive sessions. This may be due to a change in access to information, making home study much easier and leading to a feeling that the best use of time may be to hone clinical and examination skills. It is interesting that even with the advent of high-quality IT support and the scope for interaction during lectures and/or small group teaching, trainees prefer a very traditional apprentice model of teaching. Formal surgical training has been an apprenticeship since the advent of the first surgical residency training programmes pioneered in the latter part of the nineteenth century by Dr John Halstead, considered by many to be the father of surgical training.6,7 A rational explanation for trainees’ preference for this traditional model may be that ortho paedic trainees show a predisposition towards converging learning styles combining problem solving with active experimentation,5,8 though all learning styles will be present and should be accommodated for when constructing a teaching programme.9-11 Teaching with a patient or patients present was by far the most popular device, while lectures were the least popular. The educational literature is perhaps divided in the use of lectures as a vehicle to deliver teaching. There is no

doubt that lectures do have their place in medical education,12 facilitating the delivery of information to large numbers in an efficient manner. It is therefore understandable that they should be the predominant teaching modality, however our study suggests that deaneries may be sacrificing quality for the sake of such efficiency.13,14 It is possible to enhance the use of lectures such that there is higher interaction with learners, and using small or medium group techniques instead of managing the entire cohort of learners as one big group.15 Trainees or learners who are engaged in interaction within a teaching session — be it clinical, viva or lecture — are generally present in what may be considered a zone of proximal development16 as their knowledge is tested and augmented. One may consider that clinical or viva teaching, often the most interactive, pushes the trainee into this zone more so more than others, enhancing learning and understanding. The concept of scaffolding applies in this context; that peer learners and the teacher act in synergy to maximise the learning opportunity adds an additional facet to the session. The opportunity for learning with one’s peers guided by more senior teachers validates the model of situated learning.17 Value was reported in 18 (69%) deaneries in the deployment of post-exam trainees who actively engage in the teaching programme delivery. There is no doubt that the input of these trainees to teaching was appreciated. Higher surgical trainees may be considered self-directed or androgogues in their attitude to learning.18 However, the subject under study may not be reasonably covered by a truly selfdirected regime. As such, the concept of benign pedagogy as described by Bransford et al6 seems a reasonable concept in the context of a teaching programme. Deci and Ryan’s work on the psychology of goal attainment and selfdeterminism19 adds further substantiation to the concept of benign pedagogy. An educational lead may steer what is learned in a particular direction that ultimately will be mapped to the curriculum. A lecture format may be of some use to facilitate rapid dissemination of information as waypoints or markers of the level of knowledge required. Perhaps the views on lectures reflect not only the poor perceived value, but may echo the fact that postgraduate orthopaedic surgery is largely a clinical entity. The concept of a cognitive apprenticeship20 is well-established in clinical practice. A successful teaching programme would mirror this paradigm with a shift of emphasis towards a more clinical

learning. This would certainly align with the views expressed by the trainees. Interrogation of the best and worst elements of deaneries highlights pertinent comments. The responses show that trainees want easily accessible teaching sessions delivered by consultants or post-FRCS trainees in predominantly clinical or interactive sessions. They want it more frequently, with sufficient notice to ensure they can attend the sessions. There appears to be variation in how beneficial post-FRCS trainees view engagement in the teaching programme. It is interesting to note that trainees do not choose a region for training based on the quality of education delivered. This may change in time as knowledge of the quality of teaching programmes among trainees evolves. It is also likely that high-quality teaching will translate into examination success. These two influences may drive trainee choice, the best trainees selecting regions with the best teaching. This in turn may be the impetus to drive up teaching standards nationally.

Conclusion In conclusion, the UK higher surgical teaching programmes in trauma and orthopaedics show excellence in education in the form of formal teaching programmes. Formal teaching is highly valued by the trainees, and the appetite for more teaching has been established by this study. Trainees prize an interactive and/or clinical style of teaching, and least favour a lecturebased teaching mode. An excellent teaching programme will encompass all modalities (with particular attention to enhancing lectures as described above). We have outlined below factors contributing to excellence in deanery-provided teaching, which we believe extends to all medical specialties: •• •• •• •• •• •• •• •• •• •• •• ••

Timely release of locations Regular time slot Well-structured Protected teaching Consultant-delivered by experts in field National experts Wide range of teachers Engagement from post-exam trainees Innovation in lecture style More patient-centred teaching Programme mapped to the curriculum Provide adequate pre-teaching reading and materials

We hope this paper will highlight areas of excellence and act as food for thought for all TPDs and teaching leads.

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Disclaimer The authors of this paper fully accept that these are the opinions of designated representatives on deaneries and not the trainee body as a whole. We have tried to exclude bias by anonymising the results and offering anonymity to the participants.

6. Bransford JD, Brown AL, Cocking RR, et al.

16. Vygotsky L. Interaction between learning

How people learn: brain, mind, experience, and school.

and development. Cambridge: Harvard University

Washington, DC: National Academy Press, 2004.

Press,1978:79-91.

7. Cameron JL. William Stewart Halsted: our sur-

17. Lave J, Wenger E. Situated learning: legiti

gical heritage. Ann Surg 1997;22:445-458.

mate peripheral participation. Cambridge: Cambridge

8. Caulley L, Wadey V, Freeman R. Learning

University Press, 1991.

styles of first-year orthopedic surgical residents at 1

18. Knowles M. The modern practice of adult edu

accredited institution. J Surg Educ 2012;69:196-200.

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surgeons: implications for surgical education. BMC

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ate specialty training in the UK, 2013. http://

Med Educ 2010;10:51.

pursuits: human needs and the self-determination of

specialtytraining.hee.nhs.uk/files/2013/10/A-Refer-

10. Kolb DA, Fry R. Toward an applied theory of

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experiential learning. Theories of group processes.

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the-UK.pdf (date last accessed 18 October 2016).

London: John Wiley, 1975.

dent essay competitions: what makes a good engi-

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11. Lambert TW, J Goldacre M. Progression of

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syllabus_TO_2013.pdf (date last accessed 18

12. Bligh D. What’s the use of lectures? J Geogr

October 2016).

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3. Raffini J, P. Winners without losers: structures

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learn. Boston: Allyn & Bacon, 1993.

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teaching methods. Med Teach 2001;23:610-612.

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James Shelton, MRCSEd Junior British Orthopaedic Trainees Association representative; core surgical trainee, North West Deanery, UK BOTA Linkmen Collaborative S.R. Platt, FRCS james.shelton@nhs.net

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S. van de Groes P. Monk M. Lindberg-Larsen S. Cerciello

FELLOWSHIPS

European Knee Society 2015 Travelling Fellowship

he end of 2015 saw us take part in the first European Knee Society Travelling Fellowship. During a four-week period (15 November 15 to 11 December) we had the opportunity to visit some of the most important knee arthroplasty centres in Europe. The unique feature of this fellowship is the perfect balance between the scientific and surgical programme and the social activities which enhance interaction between fellows and hosts. The Fellowship began in London. Our hosts, Prof. Cobb and Prof. Amis shared their considerable experience of unicompartmental knee arthroplasty (UKA) and biomechanics in the unique atmosphere of a wonderful city. Customised UKA through patient-specific guides (PSI) are a crucial step toward the personalisation of knee arthroplasty, whereas biomechanics is a mandatory stage in understanding the principles of total and partial joint replacement. We then travelled to the medieval city of Southampton, as guests in the department of Prof. Barrett and Mr Chapman-Sheath. The surgical activities in the operating theatre were intense, with an update on the philosophy of fixed-bearing partial knee arthroplasty and revision surgery. The social programme was exciting, with incredible moments such as the informal dinner at ‘Domus Barrett’, a skittle competition and a Premier League football match in a hospitality suite. Our next stop was Brussels which we reached through the Eurotunnel when the terrorist threat was at its height. Following the trend of the previous stops we focused on partial knee arthroplasty with Prof. Thienpont and also had the opportunity to appreciate the perfect operating room organisation of Dr Stuyt. During the days in Belgium we started a series of incredible meals with three amazing dinners. The one at Dr. Stuyt’s house was particularly enjoyable for the very informal and friendly atmosphere. We next visited a fascinating capital: Berlin. Our hosts, Prof. Perka and Dr Pfitzner run a world-famous centre for the treatment of periprosthetic joint infection. Consequently,

The European Knee Society Travelling Fellows.

the discussion mainly focussed on the multidisciplinary management of these complex problems with particular emphasis on the reconstructive options in the two-stage approach. Dr Pfitzner was a great guide during our tour through the city with some incredible moments during informal dinners. We left Berlin under a light snowstorm to reach sunny Marseille. The flight was one of the unforgettable moments of the Fellowship as we experienced a ‘huge’ air pocket over the cliffs around Marseille. Prof. Argenson and Prof. Parratte run a highly efficient service, which covers all aspects of orthopaedic pathology in several city hospitals. Operations and scientific sessions were particularly intense, with discussions focussed on partial knee arthroplasty and revision cases. In the operating theatre we watched tibial osteotomies, trough PSI and several surgical approaches to complex revision cases. The social programme included memorable moments such as the league one soccer match at the Velodrome stadium and a beautiful dinner at Prof. Argenson’s home.

From Marseille we travelled to Lyon with its famous school of knee surgery. Our hosts, Prof. Lustig and Dr Bonnin work in different hospitals but have the same didactic approach to reconstructive knee surgery. In the theatre as well as in the scientific meeting, organised by Prof. Neyret, we discussed several topics including the indications, surgical tricks and outcomes of knee arthroplasty. The Lyon stop followed the trend of the fellowship, with memorable dinners and very friendly moments; however for the first time we could deal with our hosts not only in theatre but also during an indoor soccer match. From Lyon we flew to Florence, one of the most beautiful Italian cities and an important centre for revision knee arthroplasty. Our host, Dr Baldini, organised a tough programme combining, in perfect balance, recreational moments and scientific sessions. We were able to discuss the principles of bone fixation and a step-by-step surgical approach to complex revision cases, and watch several of these cases in theatre. However we also had some amazing

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informal moments with him and his staff, such as a tour of the Chianti region on quad bikes and huge dinners of typical Tuscan dishes. From Florence we drove to Pavia, our last stop, where the EKS members’ closed meeting was held. Pavia is another incredible city and Prof. Benazzo chairs one of the most prestigious university hospitals in the country. The discussion of the cases was particularly impressive and included the whole staff, including nurses, anaesthetists and residents, and was most interesting. The closed meeting was a great way to finish the Fellowship. Listening to some of the best knee surgeons in Europe present their research projects and discussing them in a friendly and confidential way

was a privilege. This Fellowship was an outstanding experience as it gave us the opportunity to meet experienced surgeons, follow them in theatre and discuss topics with them in a direct and informal manner. We then had the opportunity to deepen all of this information together during our free moments. This Fellowship was the perfect way to establish relationships with foreign colleagues and plan future scientific cooperation. We would like to thank all of the hosts for their efforts in providing this fantastic experience. Finally we would like to thank the companies whose involvement made all this possible: Zimmer, Johnson and Johnson, Medacta, Smith & Nephew and Stryker played an outstanding role in supporting the

organisation committee of this fellowship with their educational grant.

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Sebastiaan van de Groes, MD, PhD Radboudumc, Nijmegen, The Netherlands Paul Monk, FRCS (Tr&Orth) DPhil University of Oxford, UK Martin Lindberg-Larsen, MD, PhD Copenhagen University Hospital, Denmark Simone Cerciello, MD Casa di Cura Villa Betania, Rome, Italy. simone.cerciello@me.com

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FELLOWSHIPS

The Mark Paterson Travelling Fellowship 2016

D. De Kam O. Kubat M. Stiehler

Daniël De Kam (Nijmegen, The Netherlands), Dr Ozren Kubat (Zagreb, Croatia) and Dr Maik Stiehler (Dresden, Germany) took part in The Mark Paterson Travelling Fellowship between 23 May and 3 June 2016. The fellowship is a joint venture between The Bone & Joint Journal and EFORT.

Bristol The first stop was Bristol, where Mr Fergal Monsell and Prof. Ashley Blom were excellent hosts. We attended surgery and outpatient clinics in the fields of arthroplasty, trauma and paediatric orthopaedics at the Bristol Royal Infirmary and Southmead Hospital. We saw joint-preserving hip surgery as well as primary and revision arthroplasty cases and had fantastic in-depth discussions with the staff about surgical approaches, implant fixation techniques and joint bearing alternatives, among other topics. Furthermore, Dr De Kam and Dr Stiehler were involved in the management of periprosthetic femoral fractures and revision of a pseudoarthrosis following fracture surgery, while Dr Kubat attended a surgical correction of a double major curve scoliosis flawlessly performed by Mr Ian Nelson, the work of a combined orthopaedics and plastic surgery clinic led by Mr Mark Jackson, and a very interesting meeting with Dr Anna Clarke and her team who care for patients with cerebral palsy. It is important to note that the hosts and their respective teams went out of their way to make us feel welcome and show us as much as possible during our visit.

London After two days in Bristol, our next destination was University College London Hospital. Prof. Fares Haddad and his team gave us a warm welcome between 25 and 27 May. Dr De Kam and Dr Stiehler took part in joint preserving hip surgery, including periacetabular osteotomy carried out by Mr Johan Witt, knee reconstruction and lower limb computer navigated total joint arthroplasty (by Prof. Fares Haddad and Mr Sam Oussedik), while the paediatric orthopaedic team at Great Ormond Street Hospital

The Bristol Royal Infirmary team (left) and the Fellows (right), Bristol.

Dr Maik Stiehler (right) with Dr Johann Witt (second from right) and colleagues at UCLH.

ABC and Mark Paterson Fellows at The Bone & Joint Journal Offices, greeted by Prof. Fares Haddad (middle, front).

(Mr Robert Hill) allowed Dr Kubat a glimpse of the wonderful work they do every day in the operating theatres and outpatient clinic. In addition, the Fellows participated in a meeting at the editorial offices of The Bone & Joint Journal, together with the 2016 ABC Travelling Fellows during which the fellows were exposed to the history of The Bone & Joint Journal in lectures given by Prof. Haddad and colleagues.

Manchester The third place we visited was Manchester, where Prof. Peter Kay was our host. The Fellows participated in the 5th International Congress of Arthroplasty Registries (28-30 May), covering the scientific session on worldwide arthroplasty data analyses. The first day of the meeting was held at the Wrightington Hospital, where Sir

Dr Maik Stiehler, Dr Daniël De Kam and Dr Ozren Kubat, Nelson‘s Column, London.

John Charnley had carried out his pioneering work in the field of total hip arthroplasty. A highlight for the Fellows was the visit to the fascinating Charnley exhibition which displays the development of modern total joint arthroplasty. This outstanding meeting continued at the Lowry Hotel in Manchester, where the Fellows were keen to learn about new data on various arthroplasty registries and followed discussions on several aspects of arthroplasty worldwide.

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The Fellows at Lake Geneva, Switzerland. Dr Stiehler, Dr Kubat and Dr De Kam in front of the historic Hall of Wrightington Hospital. The Fellows trying out the world’s first hip simulator constructed at the John Charnley Exhibition, Wrightington Hospital. Geneva Finally, the BJJ/MP fellows took part in the 17th EFORT congress in Geneva (1-4 June). The EFORT congress was well-attended and the level of scientific and clinical research and dis-

cussions outstandingly high. Every aspect of orthopaedic surgery was well-represented, with focuses on orthogeriatrics, tribology, the obese patient, periprosthetic joint infection, and perioperative management of total joint arthroplasty. Overall, it was an excellent Fellowship featuring a lot of detailed discussions and the opportunity to network with renowned, enthusiastic orthopaedic surgeons with many lectures

and pleasant times. In total, The Mark Paterson Fellowship was the experience of a lifetime for all three Fellows. A uthor

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Daniël De Kam, Radboud University, Nijmegen, The Netherlands Ozren Kubat, Clinical Hospital Centre Zagreb, Zagreb, Croatia Maik Stiehler, Technische Universität Dresden, Germany maik.stiehler@uniklinikum-dresden.de

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K. Singisetti

FELLOWSHIPS

The Charnley Latta Travelling Scholarship report

he ENDO-Klinik is a worldrenowned orthopaedic centre in which a figure of around 7000 joint arthroplasties are carried out each year. Surgeons at this hospital have implanted more than 140 000 joint replacements since it started in 1976. The centre is also well-recognised in the field of managing prosthetic joint infection. I was introduced to the staff during the morning meeting on the first day at ENDOKlinik. There was a spectacular attendance of about 30 surgeons, all in white uniforms. A radiologist, microbiologist and several visitors to the department were also present. The meeting started at 7:10 am sharp. Radiographs of the previous day’s operations were presented and were followed by a discussion of the operations for the day ahead. I saw radiographs of several revision and complex arthroplasty procedures, but the discussion was mainly held in German. The surgeons later dispersed to their clinical work, many going to the operating theatres. The strict theatre discipline, with a particular focus on the changing of scrubs, clogs, hand washing and entry into the operating room will have a long-lasting impression on me. There were eight main theatres with laminar airflow, where joint arthroplasty surgery was being undertaken. Two theatres dealt with revision procedures for prosthetic joint infections. Theatres 5 to 8 were contained in one big hall but had separate laminar air flow tents. This was a strikingly new format for me, which I had not seen before. While most theatres dealt with hip and knee arthroplasty, I also noted that some surgeons performed shoulder replacements. The throughput in theatres was impressive. The knife-to-skin time for the first case was usually at or before 8 am. It was not unusual for surgeons to have completed three joint arthroplasties by 10 am. This is only possible with good teamwork and efficient patient flow protocols. Every person in theatre knew exactly when he or she was needed during a procedure and appeared to turn up at the correct time without any prompting. I scrubbed in for some procedures with Dr Hans Mau and Dr Udo Hessling. On the first

The author at ENDO-Klinik.

The ENDO-Klinik, Hamburg, Germany.

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assurance, packaging and sterilisation. It was an eye-opener for me to see the number of steps involved in manufacture of prosthesis used in orthopaedic surgery. We were shown some of the automated systems such as milling and turning machines, as well as the more manual tasks involving precision work. I made use of some free time to explore Hamburg and try the local cuisine, including the popular snack of ‘currywurst’. I learned a lot of tips and tricks from very experienced orthopaedic surgeons during my visit to the ENDO-Klinik, and made some friends; I will cherish the memories for a long time. This trip gave me a chance to reflect on and consolidate my experience in revision hip and knee arthroplasty surgery as I start as a consultant in the NHS. It reinforced the principles, techniques and skills in management of prosthetic joint infection, which I learned during my recently completed Cavendish hip fellowship in Sheffield. Some features of ENDO-Klinik that will have a long lasting impression on me are the strict theatre discipline, seamless throughput and awesome skills of the surgical team. Acknowledgements

The author with Dr Hessling at the ENDO-Klinik. day, I scrubbed in with Dr Hessling for a firststage revision of an infected cemented total hip. It was amazing to see his skills at the debridement, removing the prosthesis and clearing the cement mantle. He elected to do a first-stage (rather than the more common single-stage at this centre) because of uncertainty regarding the organism causing the infection. He demonstrated a novel technique of using dual mobility liners to make bespoke hip spacers, which could potentially reduce the risk of spacer dislocation. He discussed their experience with single-stage revision for prosthetic joint infection and the use of antibiotic-loaded cement spacers for twostage revision. On the second day, Dr Mau demonstrated a primary knee arthroplasty, complex primary hip

replacement for a hip dysplasia and a femoral revision for periprosthetic femur fracture. He discussed their average length of stay, protocols for antibiotic and DVT prophylaxis and rehabilitation. It was surprising to hear that they do not routinely follow-up patients after joint arthroplasty because of the sheer volume of operations performed at the centre.

I sincerely thank the John Charnley Trust for awarding me the Charnley Latta Travelling Scholarship. My visit to the ENDO-Klinik, Hamburg, Germany in August 2016 was also supported by Aquilant/LINK Orthopaedics, who arranged a trip to the LINK Factory. I would strongly recommend a visit to this clinic to other surgeons, and would be happy to be contacted to discuss any details of my visit.

The visit to the LINK factory I visited the LINK factory on the afternoon of my first day in Hamburg. The trip was previously arranged by Aquilant/LINK orthopaedics; Customer Relations Manager Mr Hauke Helden took us around their two factories in Hamburg, explaining the history of LINK, the various stages of manufacturing of a prosthesis, quality

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Mr Kiran Singisetti, Sheffield Teaching Hospitals NHS Foundation Trust, UK. kiransingisetti@gmail.com

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LETTER

J. Ridge

A response to the Editorial on junior doctors (BJJ News, Issue 10, August 2016) Sir, I applaud your recent Editorial in BJJ News outlining the misery that must prevail in our trainees’ careers. If I may point out one other factor. Practice in ‘our’ era dictated that our patients were really and truly ‘ours’. In particular, we were not offduty for any appreciable time. Occasionally of course, a patient would require some special supervision while we were

away. Under those circumstances, the covering firm would be appraised and would be vigilant. We would go off-duty, safe in the knowledge that we would return shortly, ensuring virtually seamless cover. Nowadays this has all evolved to doctoring by committee. This entails frequent, mindnumbingly boring handovers, repeated several times in any 24 hour period, with the inevitable errors and omissions that can compromise patient safety. “Many a slip twixt cup and lip”.

Personally, I was not wired up for this. Yours faithfully, Jeremy Ridge

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Jeremy Ridge, Consultant Orthopaedic Surgeon, Dewsbury, West Yorkshire, UK ridgey@doctors.org.uk

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APPRECIATION

George Simon Edmund Dowd

is a privilege to write this piece on one of the most remarkable men I have ever known. George Dowd was an SHO in children’s orthopaedics at the Liverpool Children’s Hospital in 1976 when we first met, I being the recently-appointed Professor. It was immediately obvious that he had exceptional talent in his handling of the patients, his presenting of material and his teaching. He progressed through the training programme in Liverpool and I invited him to become my first Clinical Lecturer in the academic department. At that time we were setting up a new clinic near Warrington and I invited George to organise and run this as an arm of the Liverpool department. This was done without fuss or problems and proved to be extremely successful, both for the department and also for George. One day I suggested to him that he should write an MD thesis. Together we developed the idea of using transcutaneous partial pressure (PO2) measurements of skin to predict accurately the healing of surgical wounds and also the healing of skin flaps after amputations. Once again George set about this quietly and diligently and, in liaison with the bioengineering unit and our technician, Keith Linge, he developed an excellent technique which would show precisely, from the measurements of the transcutaneous oxygen partial pressure, whether the skin would heal or not. This was a fundamental contribution to surgery and he wrote one of the best MD theses I have ever seen. In 1975 I had been approached to move to head the Academic Orthopaedic Department in the Institute of Orthopaedics of the University of London Postgraduate Medical Federation, based at the Royal National Orthopaedic Hospital (RNOH), Stanmore and at Great Portland Street. It occurred to me that it would be extremely helpful to have a talented and dependable colleague to join me in this enterprise, particularly in view of the fact that I was advised that it would be very challenging. In fact, one senior member of the profession advised me that I was mad to consider it! I spoke to George and he said that he would speak to his wife Angela and come back to me. I was astonished that within two days he came back, sat down and said, “Yes Prof, we would like to go”, and thus we moved together to London, he as Senior Lecturer and Consultant Orthopaedic Surgeon. I had not realised at the time that George loved London and also was a covert shopaholic. Together we built up the department at Stanmore as an academic and joint replacement unit, as well as a similar unit at Great Portland Street. At the invitation of our new colleagues at UCH/Middlesex, Westminster, Charing Cross, St. Bartholomew’s and associated hospitals, we set up the North London Orthopaedic Surgical Rotation based on the RNOH. We didn’t realise until much later that we were referred to as George I and George II and that the unit was referred to as “the first kingdom” – something of a compliment from our colleagues. George was a gifted teacher and also a mentor in the training programme, which by this time had built up to some 40 trainees, the largest in the UK. I realised that I directed policy and made rules, but he was the person to whom the trainees and colleagues spoke. From time to time he would gently suggest to me that we might change things or undertake new activities; his contribution was immense.

G. Bentley

9 October 1946 – 4 April 2016

George was a true polymath. To begin with he was a good-looking young man who always dressed well and had excellent taste and I began to regard him, as did many others, as a style icon He also helped to teach me how to ‘live’ in the sense that he had many outside interests and was one of the best present-givers I have ever met. While being an authority on fashion, wine, cartography, seafood and fine watches, his presents were always original and of excellent quality. He gave me an antique map of St Albans, which is one of the most treasured presents I possess. His talent as surgeon, teacher and researcher rapidly became much more apparent. We set up programmes for undergraduate as well as postgraduate teaching, an administrative structure for the department, closely linked to the RNOH, and also a research programme. We planned and discussed all of these things regularly, but in general terms with George it seemed to ‘just happen’ and the Institute, the Hospital and the patients all benefitted. Throughout of course he was supported by Angela, who was a Scarborough girl (a grand Yorkshire lass), who had known George since their teens and trained as a physiotherapist. Angela was, and remained, always positive and cheerful. I never ever saw her otherwise and never saw her angry. Together they raised three delightful daughters and, although, rather whimsically, George would from time to time grumble about being “surrounded by women”, he adored his four princesses. At this point it is probably important to mention George’s father, who I treated as a patient shortly after moving to London. He was a tough Yorkshireman who had served as a ‘Desert Rat’ with Field Marshal Montgomery at El Alamein but was one of the most unassuming individuals I have ever met. I well remember that I carried out a tibial osteotomy on him for osteoarthritis, which was at that time a fairly crude operation and quite painful post-operatively, involving several days in bed and then gradual mobilisation over four to six weeks. I went to see him on the morning after the operation to find that he had disappeared from his room in the hospital. As I left the room he approached me, walking with one stick, limping slightly, and I queried with him why he was up out of bed so quickly. He said “Oh well, it hurts a bit when I take weight on it but otherwise it is okay and I needed to go to the toilet”. This was the stock that George Dowd came from.

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George also had a delightful mother who was gentle and strong – a typical Yorkshire woman. His cherished brother Tim, with whom he was very close, also qualified in medicine and became an ophthalmic surgeon. After five years as Senior Lecturer, and reluctantly for me, we agreed that he should develop his own career which he did with outstanding distinction. Initially he moved to St Bartholomew’s Hospital, where he developed his expertise in arthroscopic surgery and initial studies on injuries of the posterior cruciate ligament (PCL). It was a challenging interest for George because knowledge was in its infancy and most surgeons thought that PCL rupture was a largely untreatable condition. He said “Everyone does ACLs,” but George not only did posterior cruciate ligament repairs but he enlightened and illuminated the whole area. He became a world authority on the topic. After several years at the merged Royal London and St.Barthlomew’s Hospital he moved to the the Royal Free Hospital where he completed 17 years as teacher, researcher and mentor to many grateful undergraduates and postgraduates. Listing his achievements seems somehow trivial, but they were considerable. Not only did he write one of the best MD theses I have ever seen, he became a Hunterian Professor of the Royal College of Surgeons and an ABC Travelling Fellow. His many publications were always thought- provoking, especially on the posterior cruciate ligament of the knee. With Paul Aichroth he was a founder of the famous Wellington Knee Clinic and later, as an appreciation of his administrative talents and deep knowledge of medicine, was invited to be Chairman of the Medical Advisory Committee of the Wellington Hospital. In retrospect, whilst I generally can say that I have had influence on many people’s careers, in some cases more than others, with George it was different in the sense that, by agreeing to join me in the new unit in

London, he was essential for the establishment of my career in London and internationally. Howard Ware has mentioned that he was “massively understated” and this crudely summarises him. In fact his whole life typified the old Yorkshire saying that “if tha’s’ got ought to say, say it, and if tha’s got nowt to say, keep it to tha sen”, or, more elegantly expressed, as “by their deeds ye shall know them”. So George was, for me, the best ever Yorkshireman. He ‘ticked all the boxes’ — he was optimistic, generous and selfless as well as being hugely talented. I came to regard him like a son and I shall be forever grateful for the opportunity to have had such a close personal relationship with him. From this you might think that I thought George was perfect. Actually he was not quite perfect but as a man, a surgeon, a teacher, researcher, colleague and friend, I know of no one who came closer.

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George Bentley profgbentley@btinternet.com

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www.bjr.boneandjoint.org.uk A Bone & Joint publication

Future orthopaedic surgeons conference 2016 Date: Saturday 10 December 2016 Venue: The Royal Society of Medicine CPD: 6 CPD credits (applied for) This annual conference invites medical students and junior doctors to hear the latest updates in orthopaedic training and selection from experts in the field, including three cutting edge practical workshops, poster exhibition & CV Q&A clinic. Lectures include: • Training, selection and jobs • Knee surgery and sports injuries • Paediatric orthopaedic surgery • Hip surgery and innovation • Life as an Orthopaedic Registrar • Upper limb surgery • Spinal surgery Workshops: • Bone cement and hemi-arthroplasty • ATLS & IM nailing • DHS and hip fracture presentation

Early bird rates expire Monday 31 October 2016:

RSM and FOSC members: £35 - £70 Non members : £45 - £90 To view the full programme and book your place visit: www.rsm.ac.uk/events/orh03 For more information contact orthopaedics@rsm.ac.uk

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Are you a surgeon in training? Subscribe to The Bone & Joint Journal (formerly JBJS Br) at a 50% discount Subscribe online at www.bjj.boneandjoint.org.uk or email subs@boneandjoint.org.uk www.bjj.boneandjoint.org.uk Follow us on twitter @BoneJointJ

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The British Editorial Society of Bone & Joint Surgery. Registered Charity No. 209299

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Arthrex Live – Knee Surgery Symposium

Wednesday, January 18, 2017 | The Ark Conference Centre | Basingstoke Live surgery and cadaveric demonstrations will be viewed in crystal clear high definition, utilising Arthrex SynergyHD4 camera systems, through live video and audio links from the operating theatre and Mobile Surgical Skills Lab.

Who should attend? The course is aimed at surgeons of all levels of experience and interest in arthroscopic knee surgery and sports injuries.

Topics will include:

■ All-Inside ACL

■ GraftLink SAMBBA ACL & ALL ■ Meniscal Repair & Transplantation ■ ACL Repair & Internal Brace™ ■ All-Inside PCL ■ Trochleoplasty and MPFL

PCL Graftlink