THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 05 / Issue 01 / March 2017 boa.ac.uk
Inside
Read the News and Updates section for the latest from the BOA and beyond
In our Features section you will find articles that focus on commissioning guides, bootcamps, allied health professionals and our regular features
For the latest update on our clinical issues, see our Subspecialty Section; the focus of this issue is shoulder surgery
News & Updates ––– Pages 02-15
Features ––– Pages 16-45
Subspecialty Section ––– Pages 46-56
Volume 05 / Issue 01 / March 2017
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JTO News and Updates
From the Editor
Contents
Phil Turner The concentrated and rapid acquisition of skills and knowledge at the start of a career is not a new concept. Commencing higher surgical training remains a daunting prospect for most trainees. The article on “Boot Camps” [cover image] explores how they get new registrars up and running, able to cope with the sudden increase in responsibility and support their incorporation into the orthopaedic community within the training programme. The BOA and BOTA are supporting their rollout across the UK (page 30). People learn in different ways and new technology makes the learning environment richer and more accessible. The BOA podcast project that was championed by the late Andy Sprowson has come to fruition with regular updates on fascinating and controversial topics (page 6). Commissioning of elective orthopaedic services is a subject that is reaching white heat. As finances get ever tighter, the criteria for referral for surgery begin to
look more like overt rationing. Balanced and transparent evidence-based commissioning would protect patients who risk unnecessary suffering, progressive immobility and dependency and worse outcomes. Ian Winson argues that enlightened shared decision-making should support both patients and surgeons in his Presidential piece on page 2. The fall in the number of Medical Students and Foundation Doctors exposed to our specialty is having a negative impact on patient care and limiting career options for those who may never consider a future in surgery. The development of “physician associates” in the extended surgical team is now gaining momentum and suitable graduates will be able to enter a specific post-graduate degree course. We will need to play a part in curriculum development and regulation, but also embrace them and see them as a positive influence on training for the whole team (page 18). Another hot topic is audit data. Some excellent advice is given on what to do if your practice is singled out at being at variance. The robust systems in place around the NJR data and the limitation of publication to unit level outcomes should support confidence in the newer registries that will cover other sub-specialties (page 22). Finally, I would like to give thanks to our Guest Editor, Duncan Tennent, who has commissioned some excellent articles on various aspects of shoulder surgery that should appeal to both the specialist and generalist.
JTO News and Updates
02–15
JTO Features
16–45
Our Commissioning Guide review: why you should care and what we’ve learnt
16
Allied Health Professionals in a modern NHS
18
What does a trauma and orthopaedic surgeon need to know about the Fracture Liaison Service Database?
20
Variance, variants, outliers and outlaws: is there a way forward for dealing with variation in audit outcomes?
22
Shoulder operations I no longer do
26
How I... manage first time traumatic anterior shoulder dislocation
28
ST3 ‘Boot Camp’ training in Trauma and Orthopaedic Surgery
30
Pro One (Amplitude Clinical): a solution for clinical outcome data collection?
32
The BOA National Clinical Leaders Programme
34
New standards for Core Trainees
36
What does a good TPD look like?
38
BOTA: how to get involved
40
How not to be an expert witness: important lessons from a recent Court case
42
Subspecialty Features
46–56
Current management of traumatic shoulder instability
46
Management of bone loss in shoulder instability
50
Review of techniques and outcomes in arthroscopic shoulder stabilisation
54
In Memoriam
57
General information and instructions for authors
60
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JTO News and Updates
Presidential Discourse Ian Winson, BOA President I am, of course, the eternal optimist. If you give me half a pint of beer I will invariably find a pint mug to pour it in and marvel at the appearance of it being more like three quarters full. So looking out, at what could be best described as a politically confusing picture, my natural tendency is to look forward and try to identify how I get to where I (hopefully we) want to be. Also, being intrinsically competitive I have to work out what team I am playing for and what plaudit I am trying to win.
Ian Winson
A glance at the WHO league table as to where we lie in that international ‘competition’ (18th) gives a pretty good target of where I would like to be; a consistent top ten finish would be good. Taking up the sporting analogy; it is usually the big spenders that get the most consistency for their investment. But it is not the only issue. The infrastructure of the club, the eyes-open approach to change, the ability to recruit and nurture the talent of the future, the ability to adjust to changes in the rules of the game, and to adopt new tactics all help.
issue of JTO, we will be well past the start of the Chinese New Year. 2017 is the year of the rooster. Roosters are said to be hardworking, resourceful, courageous and talented! If you are a rooster you have to work at avoiding bad luck this year. Tradition has it that to do this you have to avoid offending Tai Sui ‘The God of Age’. One option is to wear red (makes instant sense to a Welshman) or jade. But, the most important thing is to face in the right direction; which is away from Tai Sui. This year Tai Sui will be in the west...odd that.
In the way that things work, by the time we go to press with this
I was born in the year of the goat. “In the year of the rooster, the
goat will attain all its desired positions. It can expect a series of pleasant, positive developments, which will influence its worldview and its attitude towards life”. Ever the optimist, this all makes sense to me. Why? Because Trauma and Orthopaedics, as a whole, and the BOA in particular, has got a remarkable infrastructure which is a capable of moving forward on all fronts. When you take up the Presidential year, it is perhaps the first time you really get an overview of the whole of the BOA. What stands out is the large numbers of Trauma and Orthopaedic surgeons who do the hard yards of MSK education, research, quality improvement and patient care policies. It would be wrong of me to come up with an endless list of the people who drive this forward but in educational terms this year we do see three dedicated individuals move on from senior roles - David Limb, Mike Reed and David Large. They will be missed and their boots difficult to fill but nonetheless we have some exceptional people who have competed to replace them. Research strategies are moving Trauma and Orthopaedics front and centre both nationally and
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internationally. Converting a BOA investment of little more than £150,000 in three years to £2.5 million shows quite an impact. If we can keep on duplicating that we are all moving things forward. Our desire to understand the detail of our practices makes us pursue Big Data. Big Data comes with responsibilities but our national audits are admired by colleagues in all other specialties. The NJR has some colleagues who have had to do some really hard yards to make things work and we are getting a greater
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focus on moving towards the positive quality improvement rather than a blame culture of negative ‘outliers’. We are all largely average surgeons. Nationally, our average is high but an average surgeon working in a problem unit with the wrong prosthesis can suddenly have a performance problem. Sorting out the unit, getting the prosthesis right, puts that surgeon back where they should be. We are winning this unit level data argument to drive quality improvement forward. Getting all of the registries into this safer progressive quality
improvement programme agenda is a universal desire of all those registries. The BOA’s function is to create that structure and culture where that can happen, hence the TORUS project. Of course we do have some hard work to do in our relationships with the structures of the health service and especially the CCGs. This is far from easy but those surgeons fulfilling the Clinical Champion roles are giving us a way of having a dialogue. So, what I have seen since being President, are many people who
will stand up to be counted in difficult times. That is what makes me an optimistic goat!
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JTO News and Updates
The Instructional Course: just do it! Andreea Lupu
This two-day weekend course is an absolute goldmine for the orthopaedic trainee. Mike Reed, together with the BOA team, have revolutionised the course design. The organisation was flawless and trainees were given regular pre-course information, guidance and correspondence to help prepare them for the course.
The course consisted of a perfect balance of educational FRCS exam focused lectures, small group case-based discussion (CBD) sessions and guest lectures, and was spread across the Saturday and Sunday morning. Forty faculty were involved – all sourced because of their high quality teaching style.
Mike Reed introducing Amar Rangan who gave the Andrew Sprowson Memorial Lecture
The CBDs focused on several key topics from ISCP critical conditions or hard to get cases, and each candidate had ample opportunity to be formally assessed. Even if trainees didn’t feel prepared enough for the assessment, they could still participate and learn a huge amount during these sessions. The guest lectures were delivered by dynamic world class speakers who would certainly influence practice after the course. Professor Amar Rangan encouraged us to engage in high quality research. Professor Chris Moran’s sobering talk on the patient’s perspective was fascinating and life-changing. Dr Shiralkar tackled stress management in surgery and instantly raised awareness of the need for training in this field. David Limb provided an excellent explanation of the FRCS exam set-up with useful tips, and Ben Ollivere explained statistics
and study design. We braced ourselves during Professor Chris Colton’s ‘Alan Apley talk’ on the work following an air crash to improve safety. Finally, current BOA President, Ian Winson, closed the day with an excellent talk on the future of orthopaedics, encouraging us all to work towards creating a just culture in the NHS. Early Saturday evening the BOTA Committee provided an update on current trainee matters and encouraged solidarity amongst orthopaedic trainees. The Saturday ended with an informal drinks reception and a chance to catch up with colleagues and meet new friends which inevitably led to a great night out. The weekend provided access to a range of trainers and consultants with vast experience in their field, providing a non-threatening, fun and interactive learning environment for all.
My BOA Travelling Fellowship
Martin Raglan
I was very fortunate to travel to North America and visit two well-respected foot and ankle surgeons, Dr Steve Haddad in Chicago and Dr Lew Schon in Baltimore. The Chicago practice was predominantly a private clinic set-up whereas Baltimore was similar to a teaching hospital in the UK. Both surgeons pushed the boundaries in total ankle replacement with different management strategies, different implants but similar short-term results. I learnt and saw the operative technique of both implants and reviewed patients post-operatively in clinic. It was re-emphasised to me that it is the importance of recording outcomes and follow-up of patients that drives innovation and evolution of techniques in ankle arthroplasty.
The American healthcare system has much more money, but it isn’t necessarily better spent and there seems to be a significant amount of paperwork generated as a result of the insurance forms. Both surgeons were friendly, enthusiastic and welcomed questions about their practice, which enhanced my fellowship experience. I will take home a few tips and tricks, which I will implement in my practice. I am grateful to Dr Haddad and Dr Schon and their teams for their hospitality and thankful to the Antony Lyons Trust and the BOA for the financial support. I would strongly recommend an international fellowship to my peers as way of experiencing new ideas and new healthcare systems.
Dr Lew Schon and the team in Baltimore
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JTO News and Updates
BOA Latest News Clinical Leaders Programme: Deadline for applications approaching! The Clinical Leadership Programme (CLP) is now in its third year. The programme is an excellent opportunity to provide fellows with the support to develop their leadership capability, whilst bringing significant innovation and improvement to their given Trust or Specialist Society. There are currently three routes to gain a place on the programme; Trust funded, individually funded or appointment via a Specialist Society that is sponsoring the CLP. Due to the high interest and applications to the programme last year, the deadline for 2017/18 applications is now 31st March 2017. Further information, including how to apply, is available at www.boa.ac.uk/training-education/boa-nationalclinical-leaders-fellowships-programme.
Elective Care Reviews Following our Professional Guidance to Implement Getting it Right First Time in England, the Professional Practice Committee (PPC) is developing a programme to provide unit-level reviews of elective care. The work is still under development; however the intention is that reviews will be run by the PPC in conjunction with Specialist Societies to unlock quality improvement in units that would find this most helpful.
‘Broken Bones in Older People’ survey In collaboration with Oxford Trauma, we are funding a Research Priority Setting Partnership (PSP) through the James Lind Alliance in the area of ‘Broken Bones in Older People’. We would appreciate if you could take 10-15 minutes to complete the survey which can be found on our website at www.boa.ac.uk/ research/current-research-surveys.
Elective Care Standards
As part of our commitment to improving practice, the Professional Practice Committee has begun developing short auditable standards for elective care. These standards, BOA Elective Care Standards, will replicate the success of BOASTs in Trauma. Arthroplasty procedures recorded in the NJR are the committee’s first priority and, if not already published on our website, will be finalised shortly.
Rationing
We are continuing to identify examples of rationing by Clinical Commissioning Groups (CCGs), as well as responding to them by challenging policy in the media and by directly engaging with CCGs. Most recently we wrote to The Times, challenging false claims made by CCGs that they have good evidence to restrict surgery based on BMI and explaining the dangers of using PROMs to produce referral thresholds. You can read the letter at www.boa.ac.uk/publications/boa-letter-to-the-timesrationing-of-hip-knee-replacements-30-01-17. Further to our response in The Times Ian Winson was interviewed by Orthopaedics Today Europe on 2nd February, the full article can be read at www.boa.ac.uk/ latest-news/orthopaedics-today-europe-interview-withthe-boa-president.
New Podcasts and Screencasts Three new podcasts have recently been published on our website. Episode 11 features Sue Deakin, a consultant foot and ankle surgeon who shares a fascinating insight into her experience of establishing a Virtual Fracture Clinic. Episode 12 has Nigel Rossiter discussing the evolution of trauma care and relating it to trauma physiology. Our most recent podcast, episode 13, focuses on referrals to spine surgeons. In addition to these podcasts, there are now three new foot and ankle screencasts, which focus on the diabetic foot, ankle fractures and diabetes MDT. You can stream the podcasts and screencasts on our website at www.boa.ac.uk/training-education/orthopodcasts.
Innovation in Simulation Award Applications are open for the Innovation in Simulation award. Candidates are required to create a simulator or form of simulation for T&O surgery training purposes. The award is open to all trainers and trainees and will be presented during the BOA Congress in Liverpool. For further information, please visit www.boa.ac.uk/ training-education/boa-simulation-award.
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Commissioning Guides
Cancellation of Surgery
Over the coming months, the BOA will shortly be finalising the review of four of our NICE-accredited Commissioning Guides. These guides will act as a starting point for you to discuss service redesigns with local commissioners, to help ensure services are sustainable going forwards.
BOA President, Ian Winson, was interviewed for The Sunday Times on 10th February regarding the cancellation of surgery and the impact on surgeons and patients.
The reviews have involved literature review, discussion by a multidisciplinary Guideline Development Group and public consultation. The four guides reviewed cover: l Painful Osteoarthritis of the Knee l Painful Tingling Fingers l Pain arising from the Hip in Adults l Painful Deformed Great Toe.
RCS Associate SSL vacancy The Royal College of Surgeons of England Surgical Trials Initiative is expanding. The RCS is looking for two Trainee/ Associate Surgical Specialty Leads to work closely with the current Trauma and Orthopaedic Specialty Leads, Professor Amar Rangan and Professor Matt Costa. If you are interested in applying and would like to see the role description, please contact Laura Arnel at laura.arnel@ndorms.ox.ac.uk. More information about the RCS Surgical Trials Initiative can be found at www.rcseng.ac.uk/standards-and-research/research/ surgical-trials-initiative.
Mr Winson stated that more complex surgery might become necessary as a result of delays caused by the cancellations: “If you put in an artificial delay to surgery, that is almost certainly going to have an effect. You may have to adapt what you are doing and that may have a less good functional outcome for the patient. “The evidence is that they do not improve their pain scores to normal. They may have a substantial improvement but they don’t get to normal. “In knee arthritis, often you get deformities occurring and those deformities require more complex prostheses to go in. Deformities can progress during the wait.” The full article can be read at www.boa.ac.uk/latest-news/thesunday-times-cancellation-of-orthopaedic-surgery.
Joint Action social media is changing Last year we merged the Joint Action (JA) website into the BOA’s website. Following this, we are now moving the JA social media pages onto the BOA platform. If you already follow JA on Twitter or have liked JA on Facebook then please now follow and like the BOA social media pages. The JA Twitter and Facebook accounts will be removed on Friday 3rd March.
Tariff
Twitter: BritOrthopaedic Facebook: BritOrthopaedic
We have recently updated you on our view that the incoming two-year National Tariff for T&O is unsustainable and that NHS Improvement had thus far given an inconclusive response (www.boa.ac.uk/wp-content/uploads/2017/01/2017-01-16Ian-Winson-BOA.pdf) to our concerns (www.boa.ac.uk/wpcontent/uploads/2017/01/Letter-to-CEO-NHSI-Tariff.pdf).
We also have a LinkedIn page that you can connect to www.linkedin.com/company/the-british-orthopaedic-association. Join our 9,000 followers on Twitter, 3,500 followers on Facebook and over 3,000 followers on LinkedIn.
Subsequently, we have secured a meeting with Jim Mackey, Chief Executive of NHS Improvement, to discuss our concerns surrounding the Tariff. We will continue to keep you updated on this issue.
For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.
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JTO News and Updates
BOFAS 2016 Annual Meeting, Bristol The three-day meeting was attended by over 400 foot and ankle surgeons from around the UK. As usual, the meeting kicked off with a pre-meeting review of the TARVA (Total Ankle Replacement Vs Arthrodesis) Study lead by Andy Goldberg on the Tuesday afternoon. This study has now moved forward and is becoming an established part of our meeting. The meeting had an invited faculty from Australia, Europe and USA lecturing on a varied programme of foot and ankle disorders. Day one began by contrasting reviews on the state of flat foot compared to cavus foot disorders and treatment which then moved on to more contentious areas of plantar plate rupture and repair. Day two featured the Allied Health Professionals group discussing
The main congress hall at BOFAS 2016
sports issues. The ‘difficult cases’ session ran parallel with a varied group of workshops. The evening gala dinner was wellattended and the attendees were entertained by anecdotes from Welsh Rugby star, Scott Quinnell.
Day three rounded off with business talks and the state of treatment for ankle arthritis. Ian Winson gave a keynote talk as BOA President before the AGM and handover of the BOFAS Presidency from Bill Harries to Chris Blundell.
An electronic system was used for feedback for the first time this year which provided more than 1,000 replies from the three days. The very useful and generally supportive feedback together with suggestions will form the basis of the next congress in Sheffield in November 2017.
BTS 2016 Annual Meeting, Birmingham The annual scientific meeting of the British Trauma Society was held in Birmingham at the Council House on 9th and 10th November 2016. This was a splendid venue in the heart of the city. Altogether there were 51 paper presentations and 47 poster presentations. Five generous prizes were awarded and the winning presentations will be published in full, in ‘Injury’ shortly.
Delegates networking with trade at the BTS Meeting
There were four keynote talks, ranging from “Recent advances in acetabular surgery” by Theo Tosounidis from Leeds, “The changing face of trauma” by Professor Sir Keith Porter from Birmingham, “Current insights in the pathogenesis and management of long bone non-union” by Professor Peter Giannoudis from Leeds and “Bones and injuries in space flight” by Dr Bergita Ganse, a
prospective astronaut from Germany. There were also trade workshops. The informal layout allowed for a friendly meeting with ample opportunity to network with other delegates and with trade. Eleven CPD points were awarded for the meeting. The next BTS annual scientific meeting is being held in Sheffield on 8th and 9th November 2017 at the Mercure St Paul’s Hotel and Spa. Very shortly there will be a call for papers, earlier than previous years to allow ample time for delegates to plan their attendance. The main focus will be on multidisciplinary trauma care of the injured patient. BTS will provide a forum for all those involved in management of the injured patient; bringing together the vast knowledge and experience of surgeons, doctors, nurses, paramedics, physiotherapists, and researchers.
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JTO News and Updates
The SBPR 2016 Annual Meeting, Preston The SBPR meeting was held on 3rd-4th November at the Barton Grange Hotel, Preston and the theme was ‘New Directions’. For the first time, the meeting hosted the prestigious annual Henry Crock lecture on behalf of
the charity ‘DISCS’ (Diagnostic Investigation of Spinal Conditions and Sciatica) and was given by SBPR President Dr Lisa Roberts, on ‘New trends in communication: Improving the consultation experience’, highlighting how methodologies
Dr Lisa Roberts giving a lecture at the SBPR meeting
such as conversation analysis have been used descriptively and diagnostically within healthcare, to evaluate clinical consultations and optimise patients’ experiences and outcomes. In addition, there were excellent keynote presentations from: Dr Julia Wade, University of Bristol, on the benefits of consent in research; Dr Nick Hacking, Lancashire Teaching Hospitals, on new directions in pain management; and from Professor Justin Cobb, Imperial College London, on 3D-printing and the spine hip relationship. There was a very high standard of oral and poster presentations from clinicians and researchers in medicine, allied health and fundamental science and of course, a legendary social event
– a real highlight that included an eclectic mix of dancing! The meeting was due to conclude with a panel discussion by members of the NICE back pain guidelines group, but this was embargoed when publication of the guidelines was delayed. Instead, Dr Frances Williams from the Department of Twin Research and Genetic Epidemiology, King’s College London, gave an excellent update on the heritability of intervertebral disc degeneration and epigenetic influence on chronic pain. We are very grateful to local hosts Manoj Khatri and Jill Billington for making this an excellent meeting and look forward to the next meeting of the Society, on 2nd-3rd November 2017, in Northampton.
OTS 2017 Annual Conference, Warwick The fourth annual conference of the Orthopaedic Trauma Society was held in Warwick this year. The society has flourished since its first meeting in 2014. This was reflected in a full attendance at the meeting of 120 delegates. The format is varied with instructional sessions, research presentations, breakout sessions and keynote lectures. On the first day there were lively debates about management of ankle fractures, calcaneal fractures and wrist fractures, common injuries that have been the subject of recent UK based randomised trials that have called into question long established trends in favour of operative management. There was a striking keynote lecture from Prof Chris Moran (National Director for Trauma) on the risks and hazards associated with terrorist
attacks, highlighting the amazing response of emergency services in France to recent tragic events of this type. The day finished with instructional lectures on atypical femoral fractures, the role of bone grafting and adjuvant plating techniques. The second day opened with a thought-provoking keynote lecture from Prof Chris Colton (former President of AO International) on eLearning in the 21st century. The remainder of the second day was largely devoted to research and audit. We heard proposals for national collection of data on the outcome of ankle fractures and atypical femoral fractures in the elderly patient. The meeting continued with the now traditional ‘dragons den’ in which hopeful researchers
OTS members debating whether or not to fix calcaneal fractures and what techniques to use
pitch their research proposals for clinical studies to a critical panel of experts. The meeting concluded with the AGM and
members look forward to the next annual conference which will take place at the Bristol Marriott Hotel 10th-12th January 2018.
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JTO News and Updates
BOA Membership Update Part time membership rate for Trainees
UKITE
All programmes across UK and Ireland sat the UKITE in December, as well as one deanery in South Africa (Cape Town). We are delighted to inform you that 649 UK trainees and 20 South African trainees have successfully completed the exam. The Wales Deanery achieved the highest mean score (66%), but were closely followed by South London and West Scotland (both had a mean of 63%). The highest score in an invigilated setting was 84.2% by Sanjit Singh from the Wales Deanery. The BOA will officially reward Sanjit at the BOA Congress in September. The 2017 UKITE will run from 4th-11th December.
We are pleased to offer trainees who work part time a reduced membership rate. To apply for this rate, please complete the online application form at www.boa.ac.uk/membership/join-today, you will also be requested to submit a letter from your TPD to confirm that your appointment is for three or less days per week. Please visit the membership page www.boa.ac.uk/membership/categories-and-subscriptions for further information.
Wisepress Book of the Quarter Rockwood and Matsen’s ‘The Shoulder’
Fully updated with new technique videos, completely updated content, exciting new authors, and commentary by national and international experts in the field, Rockwood and Matsen’s ‘The Shoulder’, 5th Edition continues its tradition of excellence as the cornerstone reference for effective management of shoulder disorders. This masterwork provides how-to guidance on the full range of both tried-and-true and recent surgical techniques, including both current arthroscopic methods and the latest approaches in arthroplasty.
Authors: Charles A. Rockwood, Frederick A. Matsen, Michael A. Wirth, Steven B. Lippitt, John W. Sperling ISBN: 9780323297318 Date published: 10 Oct 2016 Price: £202.64
BOA Members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code.
BOA CONGRESS 2017 19-22 September - ACC Liverpool Quality & Innovation congress.boa.ac.uk #BOAAC
BOA Annual Congress 2017 19th-22nd September, ACC Liverpool The theme for the 2017 Congress is ‘Quality and Innovation’, which will permeate throughout all sessions. Our intention is to stimulate lively and constructive debate, insight and reflection.
will cover the remaining sessions in the programme. There is also the opportunity to attend numerous free paper sessions, led by senior members of the BOA’s Specialist Societies.
There will be the traditional plenary lectures, including the Howard Steel and Robert Jones delivered by an array of high profile speakers.
As per previous years, we will hold a series of focused educational sessions on the Friday to cater for the needs of all from Medical Students to Consultants.
Specialist topics including trauma, spines, the National Joint Registry, medico-legal issues and many more
More information can be found at congress.boa.ac.uk.
FREE* BOA member registration will open on Monday 3rd April Non-BOA member registration will open on 1st June *Terms and Conditions apply, please visit the Congress website for details - congress.boa.ac.uk
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Conference Listing: BSCOS (British Society for Children’s Orthopaedic Surgery)
www.bscos.org.uk 9-10 March 2017, Glasgow
BASS (British Association of Spinal Surgeons)
www.spinesurgeons.ac.uk 15-16 March, 2017, Manchester
BIOS (British Indian Orthopaedic Society)
www.britishindianorthopaedicsociety.org.uk 14-16 July 2017, Cumbria
BORS (British Orthopaedic Research Society) www.borsoc.org.uk 4-5 September 2017, London
BLRS (British Limb Reconstruction Society)
www.blrs.org.uk 23-24 March 2017, Leeds
BASK (British Association for Surgery of the Knee)
www.baskonline.com 28-29 March 2017, Southport
BSSH (British Society for Surgery of the Hand)
www.bssh.ac.uk 27-28 April 2017, Bath
CSOS (Combined Services Orthopaedic Society)
www.csos.co.uk 11-12 May 2017, Edinburgh
EFORT (European Federation of National Associations of Orthopaedics & Traumatology)
www.efort.org 31 May-2 June 2017, Austria
BOOS (British Orthopaedic Oncology Society)
BOA (British Orthopaedic Association) www.boa.ac.uk 19-22 September 2017, Liverpool
BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk 1-3 November 2017, Sheffield
SBPR (Society for Back Pain Research)
www.sbpr.info 2-3 November 2017, Northampton
BTS (British Trauma Society) www.bts-org.co.uk 8-9 November 2017, Sheffield
BOTA (British Orthopaedic Trainees Association)
www.boos.org.uk 2 June 2017, Newcastle
www.bota.org.uk 15-16 November 2017, Manchester
WOC (World Orthopaedic Concern)
BSS (British Scoliosis Society)
www.wocuk.org 10 June 2017, Wigan
www.britscoliosissoc.org.uk 29 November-1 December 2017, Birmingham
CAOS (Computer Assisted Orthopaedic Surgery (International))
BOSTAA (British Orthopaedic Sports Trauma & Arthroscopy Association) www.bosta.ac.uk
www.caos-international.org 14-17 June 2017, Germany
BESS (British Elbow & Shoulder Society)
www.bess.org.uk 21-23 June 2017, Coventry
6 December 2017, London
OTS (Orthopaedic Trauma Society)
www.orthopaedictrauma.org.uk 10-12 January 2018, Bristol
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JTO News and Updates
Princess of Wales Hospital team initiative helps patients understand risks of surgery Paul Lee and the team at the Princess of Wales Hospital in Bridgend, South Wales, have been looking to help patients better engage in the consent process for hip and knee surgery. The Health Foundation, in association with the BOA Clinical Leadership Programme, has awarded the hospital £75,000 to introduce this initiative. Paul is a BOA Clinical Leadership Fellow. It is now a point of law that patients have all the relevant information given to them before they can give informed consent for treatment or examination. Furthermore, it has been established in Scottish Law that we need to both document
and demonstrate the patient’s understanding and knowledge of the treatment options, their implications and risks. Unfortunately, patient feedback has revealed that many patients neither fully recall nor understand the risks of surgery following their consultation. The Princess of Wales team have used a series of bite-sized videos to explain the alternative treatment options, as well as the surgical procedures and their risks. The video scripts and graphics were developed by a multidisciplinary team of doctors, nurses, physiotherapist and patients led by Paul and Prof James Richardson.
After watching the videos, patients are asked questions in the form of a ‘check list’ to confirm their understanding of the procedure and its risks, before consent is discussed. ‘Consent Plus’ is designed to stimulate discussion, and hence comprehension, of the risks of surgery. It does not replace the current consent process. Pilot data was presented at the BOA Congress in Belfast. The next phase starts in September, and will be led by Mr Amit Chandratreya, who is also a Consultant Orthopaedic Surgeon in Bridgend.
Caption Competition Thank you to those who entered last issue’s Caption Competition. Congratulations to Ross Fawdington, whose caption was: Specsavers had 50% off! On the right is our latest photo which was taken at the recent Orthopaedic Trauma Society meeting. For your chance to win a £20 voucher, simply email your caption to jto@boa.ac.uk with the subject: Caption Competition. Please send your photos for future competitions also to this email address (no larger than 5MB).
Further information can be found at www.consentplus. com and www.health.org. uk/programmes/innovatingimprovement/projects/consentplus-improving-consentprocess-elective-hip-and.
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New JTO App launched We are excited to share the new JTO App with you. Read this issue and past issues on the go. Download now to your smartphones and tablets through the Apple App Store and GooglePlay – just search for JTO @ BOA. Let us know what you think of the JTO App, drop us a line at jto@boa.ac.uk.
Feeling active? We are looking for people to run the
British 10k Run - Sunday 9th July 2017
Will you raise money for Trauma & Orthopaedic Research? Contact us at: jointaction@boa.ac.uk / 020 7406 1767
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JTO Features
Our Commissioning Guide review: why you should care and what we’ve learnt Ian Winson By now, revised BOA guidance to CCGs*, covering four care pathways, will either have been published or imminently will be. These NICE-accredited Guides are intended to act as a starting point for surgeons when engaging with commissioners on how to improve local care pathways.
We need to focus these discussions on care that works to reduce the inefficiencies created by breaking patient care down into semi-competitive solos. I will now discuss a little more about the importance of these guides, before highlighting some of the themes coming out of the review process.
Ian Winson
As surgeons, it is logical to take on the professional responsibility to work with commissioners and colleagues across care pathways. We all know the NHS is overstretched. In those circumstances ‘quick fix’ rationing can appear to be a straightforward solution to the
immediate task of balancing budgets. But, often, quick fixes don’t work. A patient with hip arthritis, who struggles to put their socks on, will probably not be motivated to lose weight by being told they are too fat for surgery. It also seems perverse to restrict access to one of the treatments which may help to improve their general fitness (and possibly ultimately control their weight gain as a consequence) on the grounds that this might motivate them to lose weight. To move beyond this simplistic approach careful redesign of whole care pathways, starting from the initial presentation in primary care, is needed.
The conversations involved in redesigning care like this are challenging; but need to start somewhere. These Commissioning Guides provide a starting point. As they are NICE-accredited, they carry a credibility which should make initiating dialogue easier. Beyond this, the NICEaccredited process helps ensure the guidance reflects ‘on the ground’ priorities by including an element of public consultation. As part of the consultation, we pro-actively sought input from commissioners across the country and colleagues from across the multidisciplinary team, as well as from national bodies such as NHS England. A key lesson learnt is the need to embed shared-decision making thoroughly within surgical practice and all other stages of the pathway. By shared-decision making, I mean the process of enabling patients to make a joint decision about their care with you, based on both your expertise and their knowledge of their individual needs. We cannot ignore the importance of this. Some of those consulted argued that shared-decision making is now a de-facto legal necessity following the
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Montgomery ruling and made numerous comments about how practice should improve. It was widely reported that there is a need to emphasise shareddecision making at the start of a care pathway, as doing so reduces unnecessary healthcare utilisation. In consultation, there was also caution against an overreliance on patient information to achieve informed consent. Rather, clinicians should consider methods aimed to combat poor health literacy; it is an obvious observation that if patients better understand their condition they can better be involved in decisions about their care.
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Interestingly, the evidence we received on shared-decision making supported our position against rationing based on Body Mass Index. Those consulted were overwhelmingly opposed to factors, such as obesity, being barriers to referral, but often suggested that the risks presented by obesity should be with patients as part of the shareddecision making process. Maybe embedding shared-decision making across pathways would make this type of rationing, in the long run, redundant? The danger of present policies is that there are two (possibly simultaneous consequences); the general population’s fitness declines and
a large group of less fit denied patients eventually come through the system to demand the care they want: a lose/lose to the ultimate aims of cost-saving and improved general health of the population. *The BOA has been reviewing four NICE-accredited Commissioning Guides, which involves literature review, discussion by a multidisciplinary Guideline Development Group, and public consultation. The four guides reviewed cover: l Painful Osteoarthritis of the Knee l Painful Tingling Fingers l Pain arising from the Hip in Adults l Painful Deformed Great Toe.
Specific queries about this work should be sent to policy@boa.ac.uk. Ian Winson is current President of the BOA, past Editor of the JTO and a Past President of EFAS and BOFAS.
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JTO Features
Allied Health Professionals in a modern NHS Ananda Nanu The landscape is changing. There has been a gradual demise of the ‘surgical team’ or ‘firm’ and a gradual erosion of surgical education, culminating in junior doctors becoming disillusioned with a surgical career. This has been starkly expressed in the recent figures1 with only 50.4% of Foundation Trainees applying for specialty training, of the remainder, 12.7% were working or seeking to work outside the UK and 13.1% were taking a career break.
We wring our hands and tell all that we knew it would happen. The political drivers of European regulation and a failure to soft embed change to allow differences in training for the craft specialities will all be held culpable, when the dust settles. In the interim, we are left with an ageing, infirm population and a workforce that is indeterminate in strength and skill mix to cater efficiently for this. ‘Auribus teneo lupum’ we have a wolf by the ears and are likely to be bitten whether we do something or nothing. Ananda Nanu
What is clear to us is that currently, a career in
orthopaedic surgery in the UK is not as popular as it was. This is not a situation we can view with equanimity, or one that we can await emergency measures to address. Setting aside imponderables, such as the effect of Brexit on medical manpower; what can we do to improve the experience of our Foundation and Core Trainees? How can we better promote surgical careers to medical students? If we dissect out our Foundation and Core jobs and look for the kernel of interesting experiences we can impart this to our potential colleague pool; we may be able to retain more
trainees than we currently do. The question then is how we maintain or improve patient care if we divest the Foundation and Core jobs of their tedious, but essential, chores. Who in their right minds would take on the repetitive, banal but crucial aspects of the team’s duties, which are interwoven into the current workload of our Foundation and Core trainees? Assuming that Brexit, hard or soft, and the new junior doctors’ contract will not allow an increase in the working hours, the allocation of time specifically for training seems the only viable option. One solution, which is supported by the Royal College of Surgeons of England, is the Extended Surgical Team. There is, after all, a precedent for this. Most orthopaedic teams have Surgical Care Practitioners assisting in theatre, clinics and on the wards. The nomenclature varies across the country, but the practitioners are usually nurses or physiotherapists who wish to be more closely associated with direct patient care when they hit a career ceiling and promotion would mean a move to management. They provide stability and continuity. A planned increase in the number of Surgical Care Practitioners can help reduce the routine duties of junior medical staff, freeing them for
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training opportunities in craft specific skills - but nurses and physiotherapists are also in short supply. How then are we going to train and keep engaged reliable and conscientious surgical trainees in the next three years, when an acute shortfall in manpower is anticipated? Our options include cannibalising other healthcare professions, poaching professionals from countries with less attractive working conditions, or training our own citizens with an aptitude and inclination to care for others. The first two options have been explored intermittently in a haphazard fashion for nearly two decades; they have been limited by immigration controls. There is a dawning realisation that the historical choices are neither appropriate nor effective. This leaves us with the onerous task of training our own nationals from outside the existing care professions from scratch. This raises many questions; should the individuals be from a life-sciences background? Should they have a demonstrable background of caring? How can we select individuals suitable to care for the vulnerable? What level of academic achievement is necessary? Could the UKCAT score, which is used as an entry criterion for medical school,
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help select individuals? What is the course content, and who would run it? How would they progress in their careers? Who would regulate them? The Extended Role Practitioner ‘grade’ has evolved locally with little formal, national regulation. We have used professionals who are regulated either by the Healthcare and Care Professions Council or the Nursing and Midwifery Council. However, if we are to create a graduate entry scheme either a new regulatory body with statutory powers will need to be established, or one of the existing bodies will need to take on responsibility for these individuals. Career progression will also need to be addressed; a job with limited prospects of career advancement, for example in training, assessment or regulation risks withering on the vine. Practitioners will also be needed in other, surgical and non-surgical specialities. Is there a common stem to training between the practitioners in the different specialities? Curriculum development with contributions and agreement from the Royal Colleges and Specialist associations will need to be considered. To ensure that the practitioners can move, there will need to be national agreement on accreditation and regulation.
The Scottish Government produced a document on 30th June 2016, addressing the emerging roles of Physician Associates (PA) and Physician’s Assistant in Anaesthesia (PA(A)). It accepts that there is a wide variation in these individuals scope of practice and responsibilities. The document insists that the PAs and PA(A)s must work under close personal supervision at all times, with the overall responsibility for patients resting with the designated supervising doctor. The governance of these individuals and their practice has been devolved to the employing Trust. Health Education England has started work, but the timetable is tight. The career structure of Extended Care Practitioners will need to be written to create an exciting role that will attract graduates or school-leavers to a career in healthcare. I believe, in turn, this will allow us to select and train the most talented to be orthopaedic surgeons. n Ananda Nanu is the Vice President of the BOA and takes a keen interest in education. He is a Consultant Trauma and Orthopaedic Surgeon working in Sunderland.
References 1. Rimmer A. Half of foundation trainees now choose not to progress straight to specialty training. BMJ Careers 2 Feb 2017. http://careers.bmj.com/careers/ advice/Half_of_foundation_ trainees_now_choose_not_to_ progress_straight_to_specialty_ training.
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JTO Features
What does a trauma and orthopaedic surgeon need to know about the Fracture Liaison Service Database? Kassim Javaid & Xavier Griffin Patients should be assessed and managed for osteoporosis and falls risk after a fragility fracture1. Effective treatments reduce the risk of further hip fracture by 40%, spine fracture by 70% and other fractures by 30%. Recognising that most patients are not so assessed, the Department of Health has recommended Fracture Liaison Services (FLS) be commissioned locally to close this care gap. An effective FLS needs patients to be appropriately identified, investigated, treated and monitored for adherence and recurrent fractures/falls. A national audit called the FLSDatabase has recently been established to assess FLSs.
Kassim Javaid
The FLS-DB records every patient aged 50 years and over seen by the FLS. Using a similar model to the National Hip Fracture Database, the FLSDB has a live run chart of key measures including the number of patients seen and the proportion recommended for bone density measurement, a falls assessment and bone protection medication; all these metrics are compared with national averages (Figure 1).
Xavier Griffin
The first facilities audit demonstrated a wide variation in the commissioning and structures for FLS delivery2. The first patient-level audit is due to be published in April 2017 and will report how many patients are appropriately identified and managed by each FLS. The value of this audit is the yield of real world data for FLSs and Trusts. This will inform FLS commissioning, appraisal, revalidation and local quality improvement. The aim of this audit is to drive the commissioning of FLS in every NHS Trust and improve existing FLSs so every patient with a fragility fracture receives effective secondary fracture prevention. Clearly many of these patients are treated by trauma and orthopaedic services; liaison between trauma and orthopaedic surgeons and the FLS is important to ensure that both fracture management and secondary fracture prevention is delivered effectively. FLSs need your help in identifying patients who will benefit from their services – both in and out
of hospital. The FLS will then manage the patient’s bone health and falls assessment. Please discuss how you can help your local FLS identify patients; if you do not have an FLS, engage with your local care of the elderly services to develop one. The best fracture treatment is fracture prevention. n Kassim Javaid is the Associate Professor in Metabolic Bone Disease/Honorary Consultant Rheumatologist at Oxford. His research is focused on epidemiology of rare diseases of the bone and osteoporosis. Xavier Griffin is an Associate Professor of Trauma Surgery and Honorary Consultant Trauma Surgeon at University of Oxford. His research interest is in clinical and cost-effectiveness of musculoskeletal trauma interventions.
References 1. Osteoporosis: assessing the risk of fragility fracture: NICE clinical guideline 146. National Clinical Guideline Centre, NICE 2. Javaid MK, Rai S, Schoo R, Stanley R, Vasilakis N, Tsang C. Fracture Liaison Service (FLS) Database facilities audit. FLS breakpoint: opportunities for improving patient care following a fragility fracture. London: Royal College of Physicians; 2016.
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Figure 1: Sample output from FLS-DB run chart for one FLS (DXA - Dual-energy X-ray absorptiometry)
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JTO Features
Variance, variants, outliers and outlaws: is there a way forward for dealing with variation in audit outcomes? Tim Wilton A closer audit of what we do, the opportunities presented by mass data and the transparency agenda put forward by politicians, have all had a dramatic and unnerving effect upon our practice.
Many of the concerns about this are very real, but it is clear that some are due to misunderstandings, some are probably unfounded and some are due to paranoia. Of course, we live in a world where paranoia is easily induced and just because we may be paranoid doesn’t necessarily mean that people are not getting at us.
Tim Wilton
This article explains what may be expected if the data from audits and registries suggest that a surgeon’s practice is at variance - either for the better or worse compared with the norm.
The first thing to say is that the data from registries and other audits is known and accepted to be imperfect. Therefore, however aggravating and upsetting it may be to receive a notification suggesting that one’s practice may be out of line; it is important to review the data and check its accuracy. This is of course time consuming, but it is also essential. It is also clear that regularly checking the data as one goes along makes it easier to get the relevant data together if and when the ‘crunch’ comes. Checking the data also allows you to correct the data preventing the ‘crunch’ occurring in the first place.
This, of course, implies that the data are available to the surgeon. This is the case for all arthroplasty surgeons with data on the NJR, but not for most other registries. Nevertheless, by the time those registries produce outcome data for comparative audit, they should also allow feedback and data checking. In some registries, no plans have yet been formulated to examine and assess the collected data and there are no plans to do so. Some registries have stated that assessment will be confined to general examination of numbers and types of procedures and how practice is changing. In reality, as with the NJR, once the data are examined some aspects of implants’, or surgeons’, or units’ performance may come to light, which cannot be ignored. In fact, the discovery of such differences between implants or surgical performance is one of the fundamental reasons for performing these audits. This problem and dealing with it will affect us all and we cannot avoid it. In practice much
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of this data is already being collected by the hospitals and the Department of Health, and can be readily adapted to produce the sort of outcomes that some politicians would like to see made more transparent. I believe we would all prefer to be assessed against data from careful audits where we input the information, rather than poor quality administrative data such as HES. The BOA policy is to get away from terms such as ‘outlier’ which are pejorative and cause upset. Some spinal surgeons have suggested that the process
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leads to individuals feeling ‘outlawed’ and while this view is extreme, it demonstrates how upsetting it can be to have one’s practice criticised. Nevertheless, the fundamental point is that this process is not designed to be punitive, or critical; it is designed to let surgeons know what data is available about their practice and allow them to reflect and compare to others’ to facilitate improvements. This is a corner stone of surgical practice and is more-or-less universally accepted.
recently held talks with Sir Bruce Keogh and with the NJR and have reached agreement on many aspects of audit and transparency. Of particular interest is that Sir Bruce feels it is for the specialist and their Association to decide what items of data will be published. This will clearly vary between specialities, procedures and conditions.
You will no doubt be pleased to know that Ian Winson and I have
Firstly, don’t panic, but equally don’t ignore and reject the information as
So what do you do if you receive a letter saying that an aspect of your practice is out of line with your peers?
absurd. You are not being singled out or persecuted. This is an understandable first response, but until you have examined the data, neither you nor anyone else is in a position to say whether there is a problem. Under the current NJR protocol, you will have six weeks to review the data and validate it, before anyone else will be informed. If this seems too great a task, then you must seek help from your unit’s Audit Department. They are funded for this sort of enquiry and must help. If need be, it may be necessary to stop doing other >>
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JTO Features
THE BOA POLICY IS TO GET AWAY FROM TERMS SUCH AS ‘OUTLIER’ WHICH ARE PEJORATIVE AND CAUSE UPSET. SOME SPINAL SURGEONS HAVE SUGGESTED THAT THE PROCESS LEADS TO INDIVIDUALS FEELING ‘OUTLAWED’ AND WHILE THIS VIEW IS EXTREME, IT DEMONSTRATES HOW UPSETTING IT CAN BE TO HAVE ONE’S PRACTICE CRITICISED.
work during this investigation; however, we do not think this will normally be necessary.
data. This may seem surprising, but it is clearly possible to have better results because of excellent practice. We all need to understand the reason for excellence and disseminate the message more widely. In addition, some good results may be due to units or individuals not reporting or registering poor outcomes. This may be accidental as well as deliberate, but as the reporting of revision is substantially lower than that of primaries, there is clearly room for improvement of the NJR data.
There remain surgeons doing hip and knee replacements who do not look at their data. This is considered by the GMC, leaders of the NHS, and most likely by the public to be more of a problem than having a poor outcome, because it indicates an indifference to quality.
In the case of the NJR data, a tick box is going to be put on the consultant feedback part of the website to state that this has been done and to register the appraiser with whom the data was discussed. Failure to do this may in future bar the doctor from receiving clinical excellence awards.
l For the whole duration of the NJR; l For just the last five years; l The funnel plots now have
We now have broad agreement between the BOA, NJR and NHS England on how we use information from audits such as the NJR. There is also acceptance that the purpose of the process is gradually to improve quality and identify better aspects of practice. We believe this is a major step forward allowing a more constructive approach to the collection and use of registry and audit data. There is no doubt that those in high places have finally appreciated the damaging impact that such data has if it is used inappropriately, without due care and attention.
Those whose results appear significantly better than the norm also need to check the
We encourage you all to look at your data more closely; check it carefully even if it seems to be good. In this way you will get a picture of both your achievements and what you could be doing better.
The hospital does need to be informed that the unit or an individual within the unit is at significant variance, as it takes ultimate responsibility for our actions, both managerially and legally. The NJR will not inform the CEO or Medical Director until an individual surgeon has had six weeks to collate accurate information and to formulate a response. In many cases the outcome after your review will reveal data inaccuracies, or that cases with good outcomes have not been reported leading to the percentage failure rate being exaggerated. However, if there really is a higher than normal failure rate, this will need discussion and critical examination. In particular, one needs to know whether the problem relates to historical or current practice. This is more easily assessed as the NJR data are now presented in several ways:
points showing the last few years individually. This allows you to see if your results are improving or deteriorating year-on-year.
We have, therefore, agreed that during appraisal, every surgeon with nationally audited results is expected to present them for discussion and sign them off with their appraiser.
The BOA, with the assistance of the Specialist Societies, has agreed to make teams of experts available to visit and review joint replacements and other conditions, along the lines of the practice review visits for hip fractures. This will allow units where concern has been raised to approach the BOA and receive expert advice about how their practice differs from that of other units and what improvements might be of benefit. As with hip fractures, the units will be expected to contribute to the cost of the visits.
We would also like to visit those units which are doing particularly well in terms of their results and outcomes. Appreciating that it might be slightly more difficult to persuade hospitals to pay for this, we propose to negotiate with the National Director for Clinical Quality and Improvement to release funds for this particular purpose. I feel certain Tim Briggs will find supporting this worthwhile! n Tim Wilton has been a consultant arthroplasty surgeon at Royal Derby Hospital for more than 25 years and maintains an active revision practice. He is the Immediate Past President of the BOA and a Past President of BASK.
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JTO Features
Shoulder operations I no longer do Graham Tytherleigh-Strong At the time of my appointment in 2002 as a Consultant Orthopaedic Surgeon with an interest in shoulder surgery to Addenbrooke’s Hospital, the evolution of arthroscopic shoulder surgery was beginning. Led predominantly by American surgeons, new arthroscopic procedures to treat a variety of shoulder conditions were being described. Interest in shoulder surgery increased and many who were competent knee arthroscopists thought that the skills would be transferable to the shoulder. However, this has not necessarily been the case as a result of the advances in patient positioning, pump technology, fluid management, radiofrequency devices, implant and instrument design. One particular area of interest was shoulder instability - an open Bankart repair was a significant undertaking. With the introduction of arthroscopic ‘Thermal Capsular
Graham Tytherleigh-Strong
Shrinkage’, a quick and simple arthroscopic treatment seemed to be the answer to shoulder instability. The surgical technique was described for a sub-group of patients with capsular laxity with an anterior inferior predominance. A radiofrequency probe was used to ‘paint’ 3 longitudinal lines, 1cm apart, on the anterior inferior capsule in the 3 o’clock to 6 o’clock position. The thermal capsular scar was considered to cause a 67% contracture, thus tightening the capsule (Figure 1). The initial success of the procedure and the ease of the surgery led to an explosion of interest. Indications were broadened and Thermal Capsular Shrinkage procedures were undertaken for all types of instability including patients with Bankart tears and bone loss. This, coupled with a tendency to increasingly ‘paint’ more of the capsule (sometimes resulting in a complete loss of the anterior capsule or significant thermal articular damage) resulted in multiple cases of recurrent dislocation and failure. I personally undertook less than 15 Thermal Capsular Shrinkages, but revised more than twice that number of patients who were referred to me for failure. I cannot
Figure 2: An Extended Articular Surface (EAS) Copeland Resurfacing Arthroplasty
Figure 1: Radiofrequency probe undertaking a Thermal Capsular Shrinkage of the anterior inferior capsule
be completely sure this procedure has been firmly consigned to the history books, but it should be! Another challenging area for shoulder surgeons is rotator cuff arthropathy. With the absence of the rotator cuff, the humeral head migrates superiorly and the standard unconstrained humeral component is compromised. In an attempt to address this, the Extended Articular Surface (EAS) resurfacing arthroplasty was developed. This is a humeral resurfacing with an extended articular surface superiorly, which is designed to articulate with the undersurface of the acromion (Figures 2 & 3). I undertook a couple of these procedures with, at best, modest success. They improved patients’
Figure 3: X-Ray of a right shoulder after an EAS resurfacing arthroplasty
pain but did very little to reposition the head and improve movement. The Reverse Anatomy Shoulder Replacement has now superseded the EAS as it is superior, both in reducing pain and improving shoulder function. Nevertheless, only time will tell whether the Reverse Anatomy Shoulder Replacement will be the long-term answer to rotator cuff arthropathy. n Graham Tytherleigh-Strong is a Consultant Shoulder and Elbow Surgeon at Addenbrooke’s Hospital in Cambridge. He has a particular interest in arthroscopic surgery, instability and the sternoclavicular joint.
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JTO Features
How I... manage first time traumatic anterior shoulder dislocation
Peter Brownson & Karanjit Mangat Co-author: A. D. Ebinesan The shoulder is the most commonly dislocated joint; 97% of cases are anterior1,2. The management is detailed in guidelines published by the British Elbow and Shoulder Society3. This article summarises the guidelines. The risk of recurrence is inversely proportional to the patient’s age4, thus a 20 year-old male, first time dislocator has a 75% risk of recurrence, whereas a 35 year-old has a 30% risk4. Females are half as likely to re-dislocate. Older patients have a higher risk of a rotator cuff tear5. This has led to the development of an algorithm (Figure 1). Initial management Reduction should be undertaken in a controlled hospital environment using traction, and avoiding rotation (the Hippocratic method is preferable to Kocher’s). Two orthogonal radiographic views should be obtained before and after reduction. If an axial is not possible, a modified view (e.g. Wallace) is recommended6. The neurovascular
Peter Brownson
status should be documented before and after reduction. More than one week’s immobilisation7 and splinting in external rotation confer no additional advantage8. Further investigations Younger patients are at risk of further dislocation and should be referred to a shoulder specialist. In our unit, magnetic resonance arthrography is the investigation of choice. Patients between 40 and 60 have a 40% chance of a significant cuff tear5 and should ideally undergo MRI or ultrasound imaging within three weeks. Where there is a clinically relevant tear, early repair is associated with a better outcome9. Surgical options In a male aged under 25, the literature supports primary anatomic repair of a Bankart lesion. The re-dislocation rates following open or arthroscopic techniques are the same; 8% at two years10. Therefore, we advocate arthroscopic surgery using suture anchors.
Karanjit Mangat
Figure 1: Proposed algorithm for management of uncomplicated primary traumatic anterior instability1
Glenoid bone loss of more than 20% increases the risk of recurrence. We repair this with a coracoid bone block transfer (Latarjet), which has a re-dislocation rate of 8%, albeit with a higher complications rate11. Neurological injury The axillary nerve12 is most commonly injured. A neurapraxia is usual. Physiotherapy to help to maintain movements is booked. If there is no clinical recovery at six weeks, electromyography is obtained. If this does not show motor recovery, referral to a nerve injuries centre is recommended. Greater tuberosity fractures These occur in 16%, with 50% reducing following closed reduction13. Recurrent dislocation is rare in a simple anterior dislocation. Where reduction is satisfactory, weekly radiographs are obtained for four weeks. If more than 5mm of displacement is present, open reduction and internal fixation should be considered. n
Peter Brownson is a Consultant Orthopaedic Surgeon in Liverpool. He has a specialist interest in arthroscopic shoulder surgery and particularly in sports shoulder injuries. His practice involves treating players from six Premier League Football Clubs and he is the current Vice President of The British Elbow and Shoulder Society. Karanjit Mangat is a current post CCT shoulder and elbow fellow in Liverpool, having also completed the Derby hand and wrist fellowship. He undertook his higher and basic surgical training within the West Midlands, where he remains an honorary senior lecturer in orthopaedics at Aston University (Birmingham). References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Features
ST3 ‘Boot Camp’ training in Trauma and Orthopaedic Surgery Peter Dacombe Co-Authors: Greg Pickering, Richard Bamford, Mark Crowther, Steve Eastaugh-Waring, Mez Acharya Orthopaedic training in the 21st century faces a variety of challenges requiring innovative solutions. Reduced training time related to the European Working Time Directive, constant pressure to improve efficiency and a focus on quality in the wake of the GIRFT report have all impacted on the ability of orthopaedic trainees to achieve their required competencies1-3.
Great progress has been made in standardising the experience and exposure of trainees entering higher surgical training, with national selection improving transparency4. However, there remains significant variation.
Peter Dacombe
There is also an increasing national awareness of the importance of non-technical skills in orthopaedic practice. The development of generic professional capabilities in areas such as patient safety, communication and teamwork, was a key aspect of the recent Shape of Training Review5, and will play an important role in the future orthopaedic curriculum.
Boot Camp Courses An innovative approach to address these training challenges is the use of intensive, simulation-rich, ‘boot camp’ training programmes, which can be used to develop both technical and non-technical skills. A boot camp would typically occur at the beginning of the ST3 year. The duration may vary, but the camp would typically last three to five days, with an introduction to the deanery and a simulation-based programme designed to incorporate technical skills and non-technical skills. Simulation allows the recreation of workplace environments to
develop both technical and nontechnical skills in a safe, realistic, training-friendly environment6. The use of simulation in surgical training is now well-established and has the support of both the General Medical Council and Health Education England. The Joint Committee on Surgical Training recently incorporated simulation into the Intercollegiate Surgical Curriculum Programme. Pilot boot camp programmes run by the Royal College of Surgeons of Ireland, as well as programmes in cardiothoracic and neurosurgery, have shown boot camps to be an effective way to rapidly acquire knowledge associated with technical and non-technical skills7,8. Meta-analysis has shown them to consistently lead to improved clinical knowledge, technical skill and confidence in surgical trainees9.
Technical Skills Clearly it is beyond the scope of a three-day course to cover all of the technical skills required at ST3 level in orthopaedics, therefore the focus is to teach surgical skills and principles that can be applied across all subspecialty areas.
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adverse incidents, and increased mortality rates are seen in teams which communicate poorly15,16. Therefore, Human Factors training is a vital component of an orthopaedic boot camp. Surgical Human Factors training involves a series of tutorials and simulated medical scenarios, followed by reflective debriefing sessions. The programme is based on NOTTS16, with tutorials covering situational awareness, decision-making under pressure, communication, teamwork and leadership. Each tutorial is related to a simulated scenario.
A surgical cadaveric workshop
Technical Skills training is best provided in a cadaveric laboratory facility, which has audiovisual capability to allow the delivery of tutorials, expert demonstrations and supervised trainee practice. Cadaveric dissection provides excellent training in both the soft tissue and bony aspects and has been shown to improve technical skill and accuracy in orthopaedic trainees10. Virtual reality simulation, for example high fidelity arthroscopy simulators (such as the Knee Arthroscopy Surgical Trainer (KAST)) is a useful adjunct. Arthroscopy simulation has construct, predictive and face validity11, and allows the development of core arthroscopic skills. These skills are transferrable to the operating theatre12,13.
A surgical approaches cadaveric course to all of the anatomical regions can be used as the framework for developing technical skills. It is also possible to incorporate emergency procedures such as forearm/ lower limb fasciotomy, flexor sheath washout and carpal tunnel decompression into the course. Trainees may also complete PBAs to allow them structured feedback.
Non-Technical Skills Whilst technical skills are vital, and often what trainees value most, in a craft specialty it is also vital to develop nontechnical skills14. Issues related to teamwork and communication are causative factors in 70% of
Each scenario involves up to five candidates actively participating, with the rest of the group observing via monitors. The scenarios run for approximately 20 minutes and are followed by a 40-minute debriefing. This allows facilitated group discussion of any issues raised. After such training, trainees report increased confidence in the non-technical skills assessed. Ninety-one per cent say it will enhance their practice17.
Deanery Orientation The final aspect of a boot camp involves introducing trainees to their new colleagues and the key surgical trainers and administrators who will oversee their training. The course provides an excellent opportunity to meet key figures including the Training Programme Director, Royal College representatives and fellow registrars. Covering the differing roles and capabilities of the local hospitals as well as local referral pathways for major trauma, spinal emergencies, soft tissue and bone tumours, allows trainees to better understand the landscape they will practice within.
Summary The role of boot camps in trauma and orthopaedic training is in its infancy, but clearly they have a role to play in addressing some of the challenges. Early feedback from trainees has been positive, and the BOA is currently working towards a coherent, national approach to delivering boot camps. n Peter Dacombe is an ST6 in Trauma and Orthopaedic Surgery working in the Severn Deanery. He developed an interest in medical education after spending a year as the National Medical Director’s Clinical Fellow to the Director of Education at the GMC and has subsequently helped to develop the Trauma and Orthopaedic Boot Camp Course for the Severn School of Surgery.
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Features
Pro One (Amplitude Clinical): a solution for clinical outcome data collection? Dennis Kosuge
Patient reported outcome measures (PROMs) are collected routinely and are published in the public domain1. They have limitations, but most would agree that PROMs overcome clinician bias and the problems with the use of revision rates, in isolation, as a measure of success2. Individual surgeons need to take ownership of their own data collection to ensure accuracy. Soon after being appointed as a Consultant I started to use Pro One (Amplitude Clinical), a web-based outcome data collection system. Patient demographics, including an e-mail address, are inputted. Patients are e-mailed questionnaires, such as the EQ5D and Oxford Hip and Knee Score, pre-operatively. Additional information such as medical co-morbidities, operation notes in NJR format and complications are also recorded. Postoperatively patients are sent PROMs questionnaires at defined
Dennis Kosuge
intervals. A ‘Friends and Family’ test and patient recorded complications are sent in the first year. Reminders can be sent through the system. I download all of this data onto an Excel spreadsheet for analysis. Initially my main concern was whether e-mail was going to be reliable. However, I have 214 patients in my database and only 11% are unable to provide an e-mail address. Overall 71% of primary total hip arthroplasties (THA) and 91% of primary total knee arthroplasties (TKA) have completed their one-year followup data (Tables 1 and 2). I am recently appointed, and consequently the numbers are small. Nevertheless, I believe it is a start – my aim is to develop my own, career-long, ‘joint registry’. I can input complications at any time. Patients on the other hand are e-mailed to record complications at six weeks and six months. The system flags up any patient reported complications and I can amend the information. I have had one dislocation following THA. The TKAs were complicated by one intra-operative lateral condyle fracture, three patients MUA’s and two superficial wound infections. The data allows me to reflect on my practice. For example, the three TKAs requiring MUA were probably due to a combination of time required to reacquaint myself with the implant my hospital had on shelf and my more conservative approach to bone cuts initially – all were cases within six months of my
Table 1
Pre-op
6 months
Initial number of patients
% patients completing
THA – Oxford Hip Score
15.5
39.1
70
64
TKA – Oxford Knee Score
19.1
36.9
70
70
Pre-op
1 year
Initial number of patients
% patients completing
THA – Oxford Hip Score
16.4
40.1
48
77
TKA – Oxford Knee Score
19.5
37.9
47
91
Table 2
Tables 1 & 2: Mean PROM scores for THA and TKA at 6 months and 1 year
commencement. I am also trying to improve my TKA PROMs – I have focused attendance on TKA conferences in the past year and I have concentrated on others’ advice on how to achieve knee scores over 40. I accept this is only short-term data but continuous analysis will allow me to monitor my performance in the mid- and long-term. It allows me to explore ways in which I can enhance patient care. The prospectively captured data will hopefully allow me to present and publish in the future, as well as use the data for appraisal and revalidation. We work in a world where our practice and its outcomes are examined under a microscope. Pro One helps answer these concerns. I would recommend that any surgeon who wants to monitor his or her performance to take a look at Amplitude Clinical.
Other than being a user, I have no affiliations with Amplitude Clinical. n Dennis Kosuge was appointed as Consultant in Trauma and Orthopaedics at The Princess Alexandra Hospital in Harlow in 2015. Dennis was formerly on the Percival Pott Orthopaedic Rotation and at the end of his training, to pursue his subspecialty interest further, he spent a year at Royal Adelaide Hospital doing a hip arthroplasty fellowship.
References 1. NJR Surgeon and Hospital Profile. National Joint Registry (2016) at www. njrsurgeonhospitalprofile.org.uk 2. Rolfson, O. & Malchau, H. The use of patient-reported outcomes after routine arthroplasty: beyond the whys and ifs. Bone Joint J. 97B, 578–81 (2015).
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JTO Features
The BOA National Clinical Leaders Programme Simon Jameson The BOA National Clinical Leaders Programme (CLP) was established to develop the leadership skills of senior Trauma and Orthopaedic trainees, newly appointed consultants and SAS surgeons. The CLP has evolved from the BOA transitional fellowship programme and is now in its fifth year. What is the objective? To establish and nurture leadership skills with each candidate delivering an improvement project which is presented at the BOA Congress.
What does the programme involve? The course is delivered over a 12-month period with a combination of master classes, tutorials and coaching sessions from experts in a variety of fields. It is structured around four two-day study modules spread across the year (Table 1). There is also access to the online CMI Management and Leadership library. For senior trainees, this course is delivered as part of a nationally recognised clinical fellowship in their subspecialty field. For candidates in permanent positions the course runs alongside their normal job.
Simon Jameson
The first module establishes a framework for their project including its feasibility, logistics and timelines. Topics presented in subsequent modules include leadership and management in orthopaedic services, quality improvement tools and techniques, successful
negotiation, conflict resolution (do you compete, collaborate, compromise, avoid or accommodate?) and emotional intelligence (twice as important as IQ apparently!!). Candidates are expected to identify and discuss their leadership styles and recognise social motives – learning how you tick and how you can identify traits in your colleagues to gain the most for all parties (Figure 1). Invited experts, from a broad range of backgrounds, discuss service improvement projects,
Module 1 Quality Improvement in Orthopaedics QI Project planning
Leadership in healthcare Breakthrough personal effectiveness Personal development planning
evidence-based changes in practice and how to develop a successful team structure. The message is clear – initiatives with strong leadership bring out the best in staff and benefit patients, the hospital and the health service.
How is it paid for? Two-thirds of the course fee is covered by your employing Trust or sponsorship from a BOA subspecialist society. The rest is self-funded.
Where is it based? The study days are held on the outskirts of Newcastle, with hot meals and snacks provided. The modules start mid-morning on the first day and finish early on the second afternoon. This allows time for travel. The innovation project is developed and implemented over 12 months, with regular contact from the course leaders via telephone or
Module 2
Module 3
Module 4
Leading change in Orthopaedics
Inspirational leadership master class
Negotiation master class
Coaching skills
Leading teams
Dealing with conflict
Presence and impact
Motivations
Project presentation
Appraisal and revalidation
Emotional intelligence
Summary of yourself as a leader
Quality improvement, tools and techniques
Interview practice and advice
Table 1: Outline of the topics presented over the four modules
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Figure 1: Group teaching on one of the study modules
Figure 2: Innovation improvement project poster presentation at the BOA Congress
email. A poster created by each candidate describing the project, the challenges and the outcome, is presented at the BOA Congress (Figure 2).
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Prior to this project, hip and knee revision surgery was varied and not evidence-based. Pre-operative investigations were rarely performed and this compromised the planning of surgery and microbiological treatment. Local audit results showed that some ‘non-infected’ cases were actually infected; this resulted in failure necessitating further surgery.
problem joint replacement, and aimed to improve patient care, minimise morbidity and optimise resources. These pathways have been agreed at a regional level through joint infection meetings. Compared to 2015, the number of patients undergoing pre-operative blood tests has increased from 40% to 70% and aspirations have increased from 30% to 60%.
The literature supports the standardisation of the work-up and diagnosis of infection in revision arthroplasty surgery. Consensus recommendations include the use of pre-operative blood tests, joint aspiration to sample synovial fluid, and case discussion in a multidisciplinary environment.
The joint aspiration service has been developed in an under-utilised minor operations theatre, and is undertaken with local anaesthesia. This was 21% cheaper than aspirations performed in the main theatre complex. Following this work-up, every case is discussed in a multidisciplinary joint infection meeting.
My innovation improvement project helped develop a pathway for the work-up, diagnosis and management of patients presenting with a
Patient feedback supports the aspiration service with 80% of patients being highly satisfied. Theatre and junior medical staff find that the pathways and the
Reflecting on the course - six months into a consultant job Every new consultant should do this course. Some surgeons will have a greater grasp of leadership than others. Others will have demonstrable leadership skills without necessarily realising. This course has helped me to appreciate these skills and approach problems efficiently to find effective solutions. I am more aware of my interactions with others and my role as a leader. I am also amazed how commonly I use the skills, developed on this course, in everyday work.
Can I take my leadership enthusiasm further? Fellows on the programme will be given the option to follow an integrated academic module parallel to the CLP, which has accreditation for a CMI Level 7 Certificate in Strategic Management and Leadership. There is an additional cost for this programme.
What can I gain from this course? The ability to recognise one’s own skills and limitations, as well as identifying colleagues’ motivations and leadership styles. These can then be used to benefit the team. The course also allows you to meet like-minded colleagues and generate service improvement ideas.
For more information on the programme please go to www.boa.ac.uk/training-education/ boa-national-clinical-leadersfellowships-programme
An example of an innovation improvement project (Figure 3) – ‘Optimising pre-operative work-up for periprosthetic joint infections’ Periprosthetic joint infections are an enormous burden on healthcare resources. Revision of infected hip and knee prostheses costs three to four times as much as revision surgery in the absence of infection. Around 20% of revisions performed in the UK have a confirmed infection and many others may be infected. Ensuring infection is excluded prior to undertaking revision surgery optimises patient post-operative function and wellbeing and minimises hospital costs.
aspiration kits improve efficiency. They are 95% satisfied with the aspiration service.
Acknowledgements Thanks to Karen Picking, Ann Innes Smith and Mike Reed for organising a fantastic programme and to the BOA, participating NHS Trusts and Specialist Societies for their sponsorship and support. n
Figure 3: Innovation improvement project poster
Simon Jameson is a Consultant Trauma and Orthopaedic Surgeon at South Tees Hospitals NHS Foundation Trust. His specialist interests include revision hip surgery and periprosthetic joint infection. He has published and presented on several aspects of hip and knee replacement surgery and his PhD thesis focused on outcomes after primary hip replacement.
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JTO Features
New standards for Core Trainees Simon Jones The historic problems of the SHO grade led to the introduction of Core Surgery, to deliver coherent training and to try and help the trainees progress on to higher surgical training. The GMC Survey shows that 85% of Specialist Registrars are largely satisfied with their training. At Core level only 77% are satisfied. This and the Lost Tribe audit highlight problems in the early years of T&O. Thirty-three per cent of trainees reported that routine clinical work prevented them acquiring new skills. A further 24% missed training opportunities covering for absent colleagues. Training opportunities are variable; with 35% of trainees attending less than two consultant-supervised operating lists per week and 20% unable to attend the emergency theatre. Seventy-four per cent did not attend outpatients with the supervising consultant. Thirty-eight per cent of trainees use unpaid sessions to gain experience for ARCP or for ST3 application processes. Worryingly, in some cases these failings are structural, for example there is no timetabled training time or working in an elective-only hospital and there is no access to the traumabased curriculum competencies.
Simon Jones
A new curriculum for Core Training is planned for rollout in August 2017. It aims to provide a single coherent curriculum, applicable to different specialties as it has a modular structure.
Module 1 - Common content: Knowledge, clinical and technical skills giving generic competencies required by all future surgeons. This aligns with the MRCS syllabus. Module 2 - Core specialty: Knowledge and skills that all surgical trainees, whatever their final chosen speciality, should acquire from the placement in the specialty. Module 3 - ST3 preparation: Trainees work towards completion of the ST3 preparation module in their chosen specialty. These modules align with the entry expectations of the higher surgical training programmes. Modules 4 and 5: The professional behaviour and leadership skill modules common to all ISCP curricula. Whilst most of modules 1 and 2 will be undertaken in CT1, and most of module 3 in CT2, in reality elements of all five will be completed throughout the two years.
Core Surgery now has, after vigorous lobbying by the TPDs, its own Specialist Advisory Committee within the JCST (November 2016). This will hopefully raise the status and quality of Core training, as well as introducing externality to quality assure ARCP and training programmes. It should also increase adherence to the QIs already in place. The current standards for Core placements in T&O are to: l Attend five consultant
supervised sessions of four hours each week including one to two fracture clinics and two to three theatre lists
l Attend one consultant ward
round each week
l Be involved in the management
of patients presenting as an emergency at least one session each week
l Complete appropriate WBAs
assessed by consultants (> 40/ year, with a specified mix of CBD, CEX, DOPS/PBA)
l Attend one MDT per week
where appropriate.
If posts in your department do not deliver this, then, unless you make the changes, you should expect to lose the Core Trainees from them over the next year. n Simon Jones is a Consultant Orthopaedic Surgeon working in Ashington, Northumberland. He is a member of the SAC (representing Early Years) and has been Programme Director for the Core Surgery rotation in the Northern Deanery.
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JTO Features
What does a good TPD look like? Simon Hodkinson When I was asked to write this piece I wondered, “why me?”. The implication in the title is that I have been a good TPD, but that is clearly for others to decide. I will therefore confine my comments to lessons learnt and some, hopefully useful, advice for those contemplating the role.
When I started as a TPD eight years ago I was an established Consultant, who had already been a College Tutor. I thought I had some idea of what was required. The ISCP website had gone live and we had lived through MMC (Modernising Medical Careers) and the online application system - MTAS! I had had a good hand over from my predecessor and I had a very capable and knowledgeable manager.
Simon Hodkinson
Sorted! Or so I thought; but I quickly realised that I was far from sorted. There was a vast amount of information and advice I needed, and it was not always easy to find.
So what have I learnt over the last eight years and what do you need to be a good TPD? You need time and enthusiasm. Most Deaneries allot sessions to TPDs and pay the host Trust for the time; two PAs in my case. Nevertheless, there is increasing pressure from Trusts and Deaneries to limit the time allotted and paid for. Whilst this is understandable it must be resisted. The job requires time, not always on a regular basis, but when it is busy you need it. So stand your ground - 50 plus trainees require two sessions a week. I was always enthusiastic about trainees and training, however,
I have learnt it is not just an enthusiasm for the teaching and training that is required, but an interest in the totality of the individual trainee that is required. There is an ever-increasing demand for educational qualifications for TPD-like roles. Whilst this is to be applauded, I am not sure that such qualifications prepare you to deal with all of the issues that you will face. A lot of what you require is common sense, which is learnt in the University of Life. Many of us can look back on ‘bosses’ who have helped us or we have looked up to in some way or other - mentors in the modern vernacular. The recent BOTA survey raised the issue of mentoring and they have asked for more of it. Therefore, I think it is self-evident that a good TPD must try and be a good mentor. A trainee’s progress and performance can be affected by a variety of issues at work and at home. We are constantly told not to bring the home into the workplace; easier said than done. Handling such issues with empathy and understanding, whilst doing what you can to sort the issues out, helps keep the trainee on an even keel. Therefore, being
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THERE IS AN EVER-INCREASING DEMAND FOR EDUCATIONAL QUALIFICATIONS FOR TPD-LIKE ROLES. WHILST THIS IS TO BE APPLAUDED, I AM NOT SURE THAT SUCH QUALIFICATIONS PREPARE YOU TO DEAL WITH ALL OF THE ISSUES THAT YOU WILL FACE. A LOT OF WHAT YOU REQUIRE IS COMMON SENSE, WHICH IS LEARNT IN THE UNIVERSITY OF LIFE.
available to one’s trainees is vital. How you make yourself available is up to you, but many issues do not occur in working hours. I have spent many an hour in the evening and at weekends helping to sort out issues or just being available to talk. Social media has revolutionised how we communicate and many TPDs use it imaginatively - but always beware of what you and others write! You need to have good working relationships with your colleagues in the region. Thus it helps if you have a few years as a Consultant under your belt and you are ‘known’. In running any programme there will be difficult decisions to make that may affect hospitals and individual colleagues. No one likes these situations but for the good of the trainees, decisions have to be made. Whilst you need to be seen to achieve a balance of service and training, the training comes first for the TPD. Starting as a TPD I soon discovered how little I knew. So how do you get help? Thankfully in my time there has been a vast improvement in communication on training issues from the corridors of power. Involvement in the SAC has opened numerous
doors for me and the recent increase in communication with TPDs and trainees has helped immeasurably. The BOA and the RCS, in their various guises, have provided considerable support. There are now numerous meetings bringing all the parties involved in training together. I would recommend TPDs try to attend. The BOA’s TPD forum meets three times a year, at the RCS, Congress and at the BOTA annual meeting. I have found these meetings a useful forum in which to discuss matters. I have learnt a vast amount by talking to colleagues. We all have similar problems and it is helpful when all appears to be going wrong to talk to someone who has been there and done it! Occasionally, you realise that you are not as bad as you think you are. Alternatively, if you think you are good there is always someone out there doing better! Running a programme in isolation is lonely and not necessarily good for the trainees. Trainees exist in a world far more connected and informed than I, and I expect most of us, everywhere. They know what is going on! So what is the real essence of a good TPD? Fundamentally I
believe you have to care about the trainees and their future. Being a TPD is a privilege not a chore. If you feel it is a chore, then don’t do it. From my perspective I have found it to be one of the most rewarding positions I have been in in my career. It is our responsibility to ensure that the ‘best of the best’ we select at interview, develop into the best Consultants they can be. They will, after all, be looking after us in the future. They are the future! n Simon Hodkinson spent eight years as TPD in Wessex. He has been Chairman of the TPDs forum for two years and is a member of the Education and Revalidation Committee and TSC of the BOA. He is also a Trustee on the BOA Council.
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JTO Features - Trainee Section
BOTA: how to get involved Lawrence Moulton Co-Authors: Matthew Brown & Paul Hegarty The British Orthopaedic Trainees Association (BOTA) represents the professional and educational needs of UK T&O speciality registrars. BOTA also supports Foundation and Core Trainees and a Junior Representative sits on the BOTA Committee. Medical Students have been eligible to join BOTA since 2016. Trauma and Orthopaedics is the largest surgical subspecialty and BOTA was established as the representative association for UK T&O trainees.
trainee input and has a strong ethos of placing training and trainee needs at the top of the agenda. Recent BOTA initiatives include the Lost Tribe Audit, which highlighted issues related to Core Trainees. The Paediatric Orthopaedic Trauma Snapshot (POTS) was BOTA led and is the largest trainee led audit in the world. The BOTA Census also identified unacceptable levels of bullying; harassment; and undermining within our profession, and the BOA are working closely with BOTA’s new #HammerItOut campaign. We rely on the efforts of trainees to drive these initiatives forwards.
What is a Regional Representative? Today BOTA enjoys a membership of over 1,000 trainees. Although BOTA is separate from the Association of Surgeons in Training (ASiT), both organisations continue to support each other’s work through frequent collaboration, most notably in relation to the recent junior doctor contract dispute.
Lawrence Moulton
Committee members represent T&O trainees in several influential forums, including the BOA; the Royal Colleges of Surgeons of England and Edinburgh; the Joint Committee on Surgical Training (JCST) and the BMA. In addition, there is representation
on the T&O Specialty Advisory Committee (SAC) and the Intercollegiate Surgical Board (ISB) to discuss issues related to training and ensure the quality and fairness of the FRCS (Tr & Orth) examination.
Why get involved? Have you ever reviewed your training and thought “things would be so much better if…” or “the new CCT requirements aren’t realistic.”? If you have, then getting involved with BOTA may be for you. BOTA is fortunate in that its parent organisation, the BOA, values
Thirty-one Regional Representatives (formerly Linkmen) provide a connection between the BOTA committee and T&O speciality registrars from all regions (Table 2 - in the online version of this article). Becoming a Regional Representative is a great way to gain knowledge and experience about BOTA and a summary of the role is shown in Table 1. Regional Representatives are locally elected and interested trainees can contact their current representative to enable succession planning. There are two non-geographic Regional Representatives for the Armed Forces and World Orthopaedic Concern (WOC).
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What do you get from being a Regional Representative? BOTA appreciate the commitment that the Regional Representatives make. To help, BOTA organises a free leadership course every January, exclusively for Regional Representatives. The course has been well-received and is of very high quality. In addition, you will be among the first to hear about new developments, particularly curriculum and assessment updates. Finally, by disseminating information, you will be among the first to learn about educational opportunities. When your time as a Regional Representative finishes, the BOTA Vice President provides a reference for your portfolio.
What about the main BOTA Committee? The BOTA Committee comprises 17 positions (Table 3 - in the online version of this article). Committee members are elected at the AGM, which is held during our Educational Congress each year. Being a
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Regional Representative is not a pre-requisite; however, interested members should demonstrate enthusiasm and a commitment to improving T&O training. All full BOTA members, except for the Junior Representative, are eligible to vote. Full BOTA membership is available to those with a T&O National Training Number. Junior membership is available to all other doctors in approved UK training programmes (e.g. Foundation, Core or non-runthrough specialist training). Committee members are elected from across the UK. The next BOTA Educational Congress is planned for November 2017, which marks a departure from the traditional summer date.
BOTA: A Personal Perspective Being a Regional Representative should be enjoyable and be neither consuming nor interfere with your clinical training. Your primary responsibilities include
l Communicates the views of regional T&O trainees to the BOTA Committee l Communicates the activities of BOTA to fellow regional T&O trainees l Expected to attend the BOTA Educational Congress (including AGM)
and the EGM at the BOA Instructional Course
l Coordinates the local Trainer of the Year (TOTY) award process and
communicates the regional nomination to the BOTA Committee
l Expected to attend the 1-day BOTA Leadership event in January each year l Write an annual report for JOINT l Tenure not defined but usually 12-24 months Table 1: Summary of a BOTA Regional Representative’s role
coordinating your region’s annual Trainer of the Year (TOTY) nomination and writing a short annual report for JOINT, the annual BOTA publication. My experience of being on the BOTA Committee has been very positive. Not all Consultants have been positive about my holding a committee role, however most, and in particular my Training Programme Director, have been supportive. The role has provided a unique insight into the structures, complexities and issues relevant to T&O training. I have developed professional skills that would otherwise not have been possible. Through attending the annual leadership course and involvement in committee work, I have been exposed to leadership and management situations that I would otherwise have missed. The knowledge and skills I have developed will no doubt help me in clinical practice. Being aware of changes and developments as they happen, mean that you will rarely be caught out by a new compulsory assessment. Each committee position expects different levels of time-commitment; however, the majority of roles will include weekly responsibilities and project deadlines throughout the year. The BOTA Committee meets around six times over the year at locations across the UK. My lasting impression of being on the BOTA Committee will be my experience of having worked with some of the most committed and inspirational registrars in the UK. That has been such a privilege.
Conclusions BOTA can make a real difference to training, but we need people who are keen to get involved. Being a Regional Representative or a committee member can provide many opportunities. If you want to get involved, get in touch with your Regional Representative and ask what they do and how much time they commit. Alternatively, you can contact members of the BOTA Committee who will be happy to support you. n Lawrence Moulton is an ST8 in Trauma and Orthopaedics on the Oswestry-Stoke rotation, currently working at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. He is the current BOTA SAC representative and the BOTA regional rep for the OswestryStoke rotation. The online version of this article, including all of the tables, can be found at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Medico-Legal Features
How not to be an expert witness: important lessons from a recent Court case Michael Foy Any orthopaedic surgeon involved in medico-legal work is aware (or at least should be aware) that after Jones v Kaney in 20111 their immunity to prosecution has been removed and if their evidence is found to be substandard they may themselves be sued.
Therefore, it behoves all of us involved in providing expert reports to ensure that we are aware what is required of us as expert witnesses. This applies to work both in personal injury and in medical negligence. In trying to take a sensible, sustainable view in a medical negligence case I have always considered that there are five cardinal rules: l Impartiality: the report is for the
Court not the instructing party
l Stick to your own area of
expertise
l Reasonable practice/
Michael Foy
management, not Olympian or gold standard, is the benchmark l Try to analyse prospectively from the position the treating surgeon was in at the time rather than retrospectively with 20/20 hindsight l Analyse all the relevant information provided. A lot of irrelevant information will be provided. The devil is in the detail.
A recent case has been brought to my attention where the expert in a medical negligence case was severely criticised by the judge for failing to observe the basic rules outlined above and I thought it was worth reviewing the case and highlighting some of the pitfalls that we should avoid falling into ourselves. The case is instructive in as much as it highlights some other areas that are worthy of consideration in addition to those listed above. The case of Harris v Johnston2 last year involved a neurosurgeon and complications which occurred after a revision C7 foraminotomy. The claimant, a 61 year old woman, had over the years undergone a large number of spinal operations under the care of both orthopaedic surgeons and neurosurgeons. The initial operation of posterior C7 nerve root decompression was
carried out in May 2010 and the revision in November 2011 by the same neurosurgeon. The fundamental issue was whether the neurological injury that occurred at the time of the revision procedure was due to negligent performance of the operation or whether it was an “unfortunate accident� i.e. a recognised and unavoidable complication of surgery of that nature. Eminent, practicing, teaching hospital neurosurgical experts were instructed on each side. Arguments were around whether the first operation had been correctly performed and the standard of consent prior to the revision procedure, in addition to the competency of the performance of the revision procedure. However, there were a number of areas where the quality of the claimant’s expert evidence was found to be seriously lacking, resulting in criticism by the High Court Judge Mrs Justice Andrews. The expert for the claimant was critical of the operating surgeon because he had not performed an MRI scan before the first C7 decompression. He ignored the fact that because of previous failed lumbar spine surgery there was a spinal cord stimulator in situ which precluded an MRI scan. There was also an issue in relation to the actual cause >> of neurological injury at the
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JTO Medico-Legal Features
THE CLAIMANT’S EXPERT GAVE THE OPINION THAT THE FIRST C7 DECOMPRESSION HAD BEEN CARRIED OUT IN A NEGLIGENT FASHION FOR THREE REASONS. THE FIRST WAS BECAUSE THE OPERATION ONLY TOOK 30 MINUTES, THE SECOND BECAUSE THE POST-OPERATIVE CT LOOKED LITTLE DIFFERENT TO THE PRE-OPERATIVE SCAN AND THIRDLY BECAUSE THE SYMPTOMS HAD RECURRED.
second operation where the claimant’s expert appeared to confuse a Cobb dissector with a retractor. When reviewing the documentation provided to him he had not considered all the relevant material. The judge opined that he had, “based his opinion on a mistaken factual premise”. She was very critical of the fact that at the time of the preparation of a joint statement with his opposite number he had not seen fit to further consider or revise his position on these issues. The claimant’s expert gave the opinion that the first C7 decompression had been carried out in a negligent fashion for three reasons. The first was because the operation only took 30 minutes, the second because the post-operative CT looked little different to the pre-operative scan and thirdly because the symptoms had recurred. When crossexamined in the witness box by the defence barrister on each of these issues separately, he agreed that although 30 minutes for a cervical foraminotomy was quick, it was within the range of what one might expect from a reasonable and competent neurosurgeon. He also agreed that following a successful foraminotomy there may not be a great deal of difference between the pre- and post-operative scans. When
questioned he accepted that there could be recurrence of symptoms after a competently performed operation. He argued that it was the combination of these three factors which led him to the conclusion that the first operation was performed negligently. When pressed on this in the witness box he introduced the analogy of a road traffic accident in which a motorist crashed at 59mph in a 60mph speed limit area in fog and wet road conditions. He reasoned that the road traffic investigator would assimilate all these factors in concluding that the driver was driving unsafely. The judge concluded, “Whilst this is true, the analogy is flawed. The point demonstrated in the traffic accident scenario, by looking at the whole picture, is that the driver’s speed was excessive bearing in mind the factual conditions on the road, but in this case the experts agreed that the speed of the operation was not excessive. That being so, the speed of the operation cannot be transformed into negligence by two obviously neutral factors, namely the return of symptoms within a year and the inability to see on the CT scan that a significant amount of bone was removed”. On this matter Mrs Justice Andrews concluded, “This stubborn
adherence to a position which was logically indefensible was one of a number of factors which substantially undermined his credibility”. The judge also took issue with the claimant’s understanding of the Bolam test3. In crossexamination when asked about the performance of the first C7 decompression his comment was, “I think that the operation was not carried out to a standard that would be expected of, for example, an exiting exam individual”. Despite assaults on Bolam elsewhere after the Montgomery ruling4 it appears that the judiciary still rely heavily on it in cases such as this. She commented, “That led me to question in my own mind whether he had ever addressed his mind properly to the principles set out in Bolam. He should have asked himself whether what the surgeon did fell below the standards to be expected of the reasonably competent experienced neurosurgeon performing that operation on this patient, not whether an examiner would have failed a student who had done what the operating surgeon did”. During cross-examination of the claimant’s expert the defence barrister played a ‘fastball’ by questioning him on an earlier negligence case where he had acted as an
expert in order to discredit his standing as an expert in this case. The questioning was allowed because there were clearly concerns about his veracity as an expert witness. Therefore, during the trial it came to light that the expert had been criticised by a County Court Judge in a similar case a few months earlier. On that occasion he had been accused of making factual assumptions about key matters without taking any steps to check that his assumptions were correct. As a result he had to be recalled to the witness box after the erroneous assumptions were demonstrated. In the earlier case the opposing expert had accused him of “poor attention to detail”. The judge concluded, “I would have expected someone of his standing, who regularly appears before the Court in cases of this nature, to be mortified by that criticism and therefore to have taken great pains to ensure that he could not possibly be said to have made a fundamental factual error in the future by checking and double checking. It beggars belief that he would allow this to happen a second time”. Two further criticisms were made of the claimant’s expert evidence in the judgement. The first was that when crossexamined on the question of the
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neurological injury that occurred in the revision procedure he came up with two new possible mechanisms which had not previously been raised with either legal team or his opposite number. These differed from the mechanisms outlined in his report on liability and had not been raised in the joint statement nor put to the surgeon who was accused of negligence. These further hypotheses were therefore discounted by the judge and taken as further evidence of his unreliability as an expert witness. The second was his failure to comply with part 35 of the Civil Procedure Rules (CPR). The declaration at the end of his written report and in the joint report indicated that he had done his best in the report to be accurate and complete, but, according to the judge, “he had plainly done nothing of the kind”. Therefore, in light of all these factors Mrs Justice Andrews concluded, “His general intransigence, his sloppy attention to detail and his failure to abide by his duties as an independent expert did not just lead me to question his reliability, it left me with no confidence in him. It is bad enough that he fell so far short of the standards to be expected of an expert witness in this case, but what makes it particularly serious is that he
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did so against a background where another judge had said for very similar reasons that her confidence in the reliability and impartiality of his evidence had been so severely undermined that she would treat it with great caution. This therefore was not an isolated aberration”. On this basis she dismissed the claimant’s expert evidence and relied on that of the defence expert who she described as, “The model of an independent and impartial expert, balanced, fair and objective”. The claim for damages, set at £725,000, was dismissed. There is much to learn from this case. We are not immune from criticism, rebuke or litigation. Within an adversarial system as exists in this country, each side will seek, wherever possible to discredit the expert evidence of the other side. In Harris v Johnston it appears that the claimant’s expert evidence made this relatively straightforward for the defence legal team. Therefore, on the basis of this case there are further rules that we can add to those outlined above: l Don’t take logically
indefensible positions
l Don’t have an intransigent
mind set
l Understand the legal tests and
processes that will be applied to the issues under consideration
l Learn from errors or mistakes.
Mature reflection is part of the appraisal process in clinical practice and can be equally well applied to expert witness work l In reality, fewer and fewer claims of this nature seem to end up in Court. Sensible, well thought through, impartial opinions from experts who are familiar with the territory should continue to ensure that this is the case. n Michael Foy is a Consultant Orthopaedic and Spinal Surgeon, is Chairman of the BOA’s Medicolegal Committee, co-author of Medico-legal Reporting in Orthopaedic Trauma and author of various papers on medico-legal and spinal/orthopaedic issues.
References 1. Jones v Kaney (2011) UKSC 13 2. Harris v Johnston (2016) EWHC 3193 3. Bolam v Friern Hospital Management Committee (1957) 1 WLR 582 4. Badenoch J A doctors duty of disclosure and the decline of the Bolam test: A dramatic change in the law on patient consent (2016) Medico-Legal Journal 84: 5-17
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JTO Subspecialty Section
Current management of traumatic shoulder instability James Tyler Co-authors: Niv Bhamber & Eyiyemi Pearse Shoulder instability is defined as the abnormal and symptomatic movement of the humeral head across the face of the glenoid fossa1. This is caused by failure of the stabilising mechanisms of the shoulder. The extent of this abnormal translation will determine the severity of the presenting symptoms2. Minimal translation causes apprehension or pain. Moderate translation causes subluxation; patients report this as a feeling of instability or the shoulder slipping in and out. Finally, extreme translation will lead to full dislocation.
Traumatic shoulder dislocation Acute shoulder dislocation is common with a reported incidence of 11 to 44 per 100,000 person years3-6. To put this in context, the incidence of wrist fractures is 62 per 100,000 person years. There is a bimodal age distribution with peaks in the 3rd and 9th decade. Athletes and males are at particular risk3,4,6.
James Tyler
For many patients an acute traumatic shoulder dislocation is an isolated event. For others, damage to the
stabilising mechanisms of the shoulder impairs their function resulting in recurrent instability. It is reported that about 26% of patients will go on to further dislocation within four years. This increases in younger patients and if the patient is under 20 years of age their risk of further dislocation goes up to between 64 and 87%5,7. Injuries associated with acute traumatic shoulder dislocation include neurological injury (48% incidence on EMG but only 13% clinically evident)6,8, vascular injuries, rotator cuff tears in patients older than 40 and greater tuberosity fractures.
Management of traumatic shoulder dislocation There are three key aspects of the management of the traumatically dislocated shoulder: 1. Safe and expeditious reduction of the acute dislocation (this will not be covered in this article) 2. Initial treatment of the recently reduced shoulder with the management of pain, restoration of function and prevention of further episodes of instability 3. Management of recurrent episodes of instability, if they occur. This requires an understanding of the cause of recurrent instability and the strategies to address them.
Initial treatment of the recently reduced shoulder The patient should be placed in a simple broad arm sling to manage pain. This should be removed and the shoulder mobilised as pain allows9. Prolonged use of a sling with the shoulder immobilised in either internal or external rotation does not reduce the risk of recurrence10-12. The role of acute surgery is controversial. Arthroscopic washout does not reduce the risk of further dislocation13. A recent Cochrane review14 supports acute stabilisation in the young contact
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athlete, however, most patients only undergo surgical treatment after a second dislocation. Further imaging is of value if a rotator cuff tear is suspected (patients over the age of 40) or for surgical planning.
Management of recurrent traumatic instability Surgical strategies to manage recurrent instability are based on an understanding of the biomechanics and anatomy of the normal shoulder and how these fail.
Biomechanics There is an inverse relationship between range of movement and intrinsic stability in every joint. The intrinsic or static components of stability are determined by bony anatomy15 and the ligaments and capsular condensations16. The shoulder has a wide range of movement to allow precise positioning of the hand in space. This is achieved at the expense of intrinsic stability. There is minimal bony constraint of the shoulder. The glenoid concavity is deepened by the glenoid labrum and the non-uniform distribution of the articular cartilage. This increases the static constraint of the shoulder17. The glenohumeral ligaments constrain the
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movement of the humeral head but only become tight at the extremes of range of shoulder range. The ligaments also have a relatively poor mechanical load to failure with a mean ultimate load of 585N18, this compares to 2160N for the anterior cruciate ligament19. Therefore, the shoulder relies heavily on its dynamic stabilisers: a complex interaction of muscle forces simultaneously effect rotational movement of the humeral head whilst minimising translational movements (Table 1). These automatic muscle patterns require sensory inputs to locate the humeral head relative to the glenoid, so they “know� how hard to pull. The capsule and labrum Static:
have abundant proprioceptive mechanoreceptors20 to feedback the humeral head position and allow the dynamic stabilisers to function appropriately21 (Figure 1). The capsuloligamentous-labral complex, therefore, functions both as a static stabiliser as well as the efferent limb of the proprioceptive feedback loop (Figure 2).
The stabilisation mechanism fails in predictable ways: 1. A catastrophic load in which the speed of application and magnitude overcome both static and dynamic stabilisers and leads to traumatic dislocation 2. Recurrent instability occurs after a traumatic dislocation if it causes a structural abnormality of both the static and dynamic stabilisers 3. The stabilisers can be congenitally deficient
Figure 1: The Afferent/Efferent stability pathway
l Bony anatomy15 l Glenoid labrum17 l Capsular ligaments16: l Superior glenohumeral ligament l Middle glenohumeral ligament l Inferior glenohumeral ligament l Negative intra-articular pressure33
4. The efferent/afferent dynamic stabilisation loop can become disordered in the absence of structural abnormality. This categorisation explains the origin of the most widely used and accepted clinical classification of recurrent shoulder instability: the Bayley or Stanmore triangle (Figure 3)1. This system describes three polar types:
Dynamic: l Efferent: Proprioception21 l Afferent: Rotator Cuff musculature: l Supraspinatus l Infraspinatus l Subscapularis l Teres Minor Table 1: Structures that stabilise the shoulder
Mechanisms of stabiliser failure
l Polar type I: Traumatic
Figure 2: The centred and un-centred humeral head
structural (analogous to TUBs in the Thomas and Matsen classification22) l Polar type II: Atraumatic structural analogous to AMBRI in the Thomas and Matsen classification22) l Polar type III: Muscle patterning non-structural. >>
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JTO Subspecialty Section
in traumatic anterior shoulder dislocation. The labrum is pulled from the glenoid and the glenoid neck periosteum ruptures, thus detaching the labrum from the glenoid24 (Figure 4). ALPSA lesion: Anterior Labroligamentous Periosteal Sleeve Avulsion. This is also an anterior labral pathology, but differs from a Bankart lesion as the glenoid periosteum remains intact. In this situation the labrum falls medially onto the glenoid neck25 (Figure 5). Figure 3: The Stanmore triangle1
Patients with instability who have a type I or II component may benefit from surgery to correct the structural pathology. Patients with pure polar type III instability will not benefit from surgery and may indeed be harmed as they will have an increased risk of arthritis and rehabilitation failure23. In this article we will concentrate on polar type I (recurrent traumatic) instability where trauma has caused a structural abnormality damaging both the static and dynamic stabilisers.
Figure 4: The dislocated shoulder with a Bankart injury
In general, ligaments fail at their origin or insertion, not in their mid-substance. Structural failure of the capsuloligamentous-labral complex occurs most commonly at the interface between the labrum and the glenoid, but occasionally failure occurs at the humeral insertion of the capsular ligaments18. Avulsion of the capsuloligamentous complex from the glenoid: Bankart tear: The typical anterior labral pathology seen
Figure 5: An ALPSA with a lax anterior capsule
Perthes lesion: This lesion is very similar to an ALPSA, the glenoid periosteum is again intact; the labrum is avulsed from the glenoid but not displaced. This is hard to visualise on MR imaging, but can still lead to instability26 (Figure 6). Avulsion of the capsuloligamentous complex from the humeral head: HAGL: Humeral Avulsion of Glenohumeral Ligament. This lesion is seen when the capsule and its ligamentous structures are torn from the humerus during the dislocation27.
Figure 6: A shoulder dislocating to give a Perthes lesion
Bone defects: Bony Bankart: This lesion is an anterior glenoid fracture. The anterior labrum is still attached to the detached bone fragment28. Hill Sachs lesion: The glenoid impacts into the posterior humeral head when it dislocates stripping the cartilage and creating a defect in the posterosuperior humeral head. This lesion may ‘engage’ on the anterior glenoid rim during movement leading to instability29. Pathological changes in the capsuloligamentous complex: It is our assertion that prior to avulsion of the capsuloligamentous complex from either the humeral head or the glenoid, the elastic limit of the capsuloligamentous complex is exceeded and plastic deformation occurs (Figure 7). The amount of plastic change will depend on the compliance of the tissues: the older the patient, the less compliant the tissues are and the less permanent is the change in length of the capsuloligamentous complex. We postulate that this results in less disruption and hence the reduced chance of re-dislocation in older patients.
Figure 7: A shoulder dislocating prior to anterior capsule becoming tight due to plastic deformation
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Investigation of recurrent traumatic instability
open procedures continue to be performed.
MRI and CT arthrography have both been used to evaluate the post-dislocation anatomical damage. They both have their merits, but MRI has significant advantages when evaluating the soft tissue structures, especially labral tears (sensitivity 44–100%, specificity 66–95%). MR with arthrography has a sensitivity of 86% and 91% and a specificity of 86–98% for labral pathology. In view of this, MRI arthrography is the investigation of choice. It is generally accepted that CT is the superior modality for assessing bone pathology30.
Open procedures: The aim of most open soft tissue repairs is to re-tension the anterior capsule, particularly the anterior band of the inferior glenohumeral ligament. This can be done by double breasting the anterior capsule with a T shaped capsular incision (Neer and Foster or Altchek). Historically, both the capsule and the subscapularis were tightened (Putti-Platt or Magnuson-Stack). Although the Putti-Platt repair had high levels of success in treating instability, it resulted in increased joint reaction forces and was associated with a high incidence of joint degeneration31.
Surgical management of recurrent traumatic instability Open techniques to manage shoulder instability were first used in the late 1800’s, but were very different from the techniques of today31. It was not until the 1920’s when Bankart described his eponymous lesion24 that techniques were commonly used to repair defined anatomical injuries. Since then there has been a progression of open and then arthroscopic techniques to deal with the anatomical deficiencies that lead to recurrent shoulder instability. This article focuses on the management of recurrent instability in the absence of significant glenoid or humeral head bone loss. Most soft tissue repair procedures performed in the UK currently are arthroscopic9, but some
Arthroscopic procedures: In an arthroscopic repair the anatomical lesion is identified and repaired. The most common variation is the Bankart repair32. The labrum is elevated from the anterior glenoid neck; the neck is prepared to bleeding bone and the labrum repaired using two or three bone anchors to the face of the glenoid. In addition to the labral repair, the capsule is re-tensioned. This can be achieved in a variety of ways, including reefing of the capsule or attaching the repair to the glenoid face rather than the glenoid edge and shifting the capsule superiorly. This type of repair can also be utilised for ALPSA and Perthes lesions. A HAGL can also be treated arthroscopically. In this situation, the torn inferior capsule is repaired with bone anchors to the humerus.
Rehabilitation after surgery
Correspondence
The role of rehabilitation after stabilisation surgery moves through three phases: Phase 1: Protection of healing repair Phase 2: Regain normal ROM Phase 3: Regain power, endurance and shoulder control to allow return to desired function.
Email: jamestyler@doctors.org.uk
Conclusions Traumatic anterior shoulder instability is an evolving area, but there are helpful guidelines to facilitate decision making in the clinical environment. It is essential to assess the patient carefully and to establish which structures are likely to have been injured. The patient can be mobilised early. The decision on further imaging should be based on the likelihood of the need for surgical intervention. Once a patient has developed recurrent instability it is essential to make on the type of surgery to perform in an effort to avoid recurrence. n James Tyler is currently a Post CCT Upper Limb Fellow at St Georges University Hospitals NHS Foundation Trust. He has an interest in shoulder surgery and sports orthopaedics. He has a Postgraduate diploma in sports and exercise medicine. His MSc dissertation investigated shoulder outcome scoring systems and he has previously completed a fellowship at the Perth Orthopaedics and Sports Medicine Centre in Western Australia.
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Subspecialty Section
Management of bone loss in shoulder instability Chu-Hao Chiang Co-Authors: Abhinav Gulihar & Nicholas Little
Management
Management of glenohumeral joint (GHJ) instability can be challenging in the presence of structural bone defects of the glenoid or humerus. The presence of glenoid or humeral bone loss has been shown to be an important factor in the failure of arthroscopic stabilisation of the GHJ1. Therefore, it is important to recognise the presence of any bone defects prior to surgery in patients with instability.
The average anterior/posterior dimensions of the glenoid is 24 to 26 millimetres. Therefore, even a minor bone defect of 6 to 8 millimetres represent about 25% glenoid bone loss2. Lo et al. described the inverted pear shaped glenoid which is usually associated with a significant structural defect of greater than 30%3.
Chu-Hao Chiang
Plain radiographs should include an antero-posterior view with the shoulder in internal rotation to demonstrate a Hill-Sachs lesion and a glenoid profile view to assess for anterior glenoid bone loss. The presence of a Hill-Sachs on an external rotation view usually indicates a large lesion4. Computed Tomography (CT) scans with 3D construction
allow visualisation of the defect’s size and location (Figure 1). Bone loss can also be measured intraoperatively (Figure 2)3.
Figure 1: Pre-operative CT scan demonstrating glenoid bone loss
Yamamoto et al. demonstrated through cadaveric biomechanical studies that glenoid bone loss of 25% led to significant instability5,6. This figure has been confirmed by Burkhart et al. who noted a 67% failure rate of Bankart repairs in patients with greater than 25% glenoid bone loss, compared with 4% in those without bone loss1. However, cadaveric studies have shown glenoid bone loss of 15% leads to instability7. Consequently, Balg et al. suggested that young patients, with higher demands, would benefit from reconstruction of glenoid bone loss of 15% or more4. We believe that bone loss of more than 20% should be reconstructed using autologous >>
Figure 2: Intraoperative image from superior viewing portal demonstrating anterior glenoid bone loss
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JTO Subspecialty Section
A META-ANALYSIS COMPARING OPEN AND ARTHROSCOPIC LATARJET PROCEDURE FOUND THAT ALTHOUGH THEY BOTH PROVIDED A COMPARABLE CLINICAL OUTCOME WITH A LESS THAN 3.5% RECURRENCE RATE, THE ARTHROSCOPIC PROCEDURE WAS SIGNIFICANTLY MORE EXPENSIVE AS A RESULT OF THE LONGER OPERATION TIME AND THE USE OF ADDITIONAL EQUIPMENT.
graft – either tricortical (commonly from the iliac crest) – or an ipsilateral coracoid transfer – Bristow or Laterjet procedure (Figures 3 and 4). Although good results have been obtained with tricortical iliac crest, proponents of the Latarjet procedure argue that the dynamic sling provided by the conjoint tendon, combined with inferiorisation of the subscapularis muscle provides additional stability8,9. Young et al. published the largest
Figure 3: AP Film after a Latarjet repair
case series of 2,000 patients undergoing Latarjet procedures and noted a failure rate of 1%, with 83% of patients returning to their preinjury sports10. The Latarjet procedure can also be undertaken arthroscopically. A meta-analysis comparing open and arthroscopic Latarjet procedure found that although they both provided a comparable clinical outcome with a less than 3.5% recurrence rate, the arthroscopic procedure was significantly more expensive as a result of the longer operation time and the use of additional equipment11. Although infrequent, glenoid bone loss can occur posteriorly. There are varied results in the literature. Barbier et al. published a case series of eight patients who underwent tricortical bone grafting for posterior glenoid bone loss. At three year follow up 80% of patients reported a satisfactory outcome, although none had resumed their normal sporting activities at the preinjury level12. In a different series of fifteen patients, Struck et al. had satisfactory results and 67% had resumed sport at the preinjury level13.
Humeral Bone Loss
Figure 4: Axillary film after a Latarjet repair
Posterior humeral defects are reconstructed according to their size and depth. Hill-Sachs lesions under 20% are treated conservatively14. Lesions of more than 20% can be managed
either by filling the defect or resurfacing the humeral head. Hill-Sachs lesions between 20% and 30% are more likely to involve the articulation, thus they would benefit from remplissage. Remplissage involves the tenodesis of the infraspinatus tendon into the defect. Buza et al. published a systematic review of six studies on the use of arthroscopic remplissage and found an overall 5.4% recurrence rate in 167 patients15. The management of Hill-Sachs lesions between 30% and 40% is controversial. Patients with defects of this size can be potentially managed with remplissage, an osteochondral allograft transplantation (OAT) procedure or a partial resurfacing prosthesis such as HemiCap14. Garcia et al. published a case series comparing 19 patients who underwent OAT procedures and 20 who underwent remplissage. They reported a 50% decrease in the recurrence rate with the remplissage technique16. Miniaci reported a case series of 18 patients who underwent OAT procedure and reported no recurrences17. Although, a systematic review of 12 studies including 35 patients reported that though there was a significant improvement in their shoulder motion and only 3% of patients suffered from recurrent instability, there was a 32% incidence of residual pain and a complication rate of 22%18.
In lesions involving greater than 40% of the joint surface, patients require either partial resurfacing or a shoulder arthroplasty. Sweet et al. published a retrospective case series of nineteen patients treated with a HemiCAP and reported no major complications19.
Bipolar Defects Bone loss on both the glenoid and the humeral head (bipolar defects) following dislocation has a prevalence rate of 33% in primary instability and 62% in recurrent instability20. A CT study of 100 patients reported an even higher incidence of bone loss with Hills-Sachs lesions in 94% and glenoid bone loss in 86% of patients21. Burkhart et al. identified that if a Hill-Sachs lesion ‘engaged’ with the glenoid at 90o of external rotation and abduction, the shoulder was at high risk of recurrence dislocation despite a Bankart repair1. Yamamoto et al. further identified an area they defined as the glenoid track5. This is a band of the articular surface on the postero-superior humeral head. Bone loss outside this area is associated with a loss of stability5,22. If there is glenoid bone loss, then the glenoid track reduces in width. A Hill-Sachs lesion that lies within the area of the glenoid track is said to be ‘on-track’, whereas one that lies outside is ‘off-track’23. An off-track lesion is associated with an increased
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risk of failure following soft tissue Bankart repair alone1. Tracking has redefined the management of bipolar bony defects. Shaha et al. published a case series, which confirmed that the glenoid track concept was a better predictor of the failure of arthroscopic stabilisation than the measurement of glenoid bone loss24. It therefore follows that on-track lesions
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can be successfully treated with arthroscopic stabilisation alone. The aim of treating off-track lesions is to turn them into ontrack lesions. This can be done by treating the humeral bone loss or increasing the glenoid track. The use of the Latarjet procedure to enlarge the glenoid track and converting an off-track Hill-Sachs lesion to an on-track has been reported, but no longterm follow up results have been
published21,25. Using tracking we believe that an algorithm can be used for managing these patients (Figure 5).
Conclusion Bone loss post GHJ dislocation is a challenging problem. Pre-operative and intra-operative planning is of paramount importance to
*
avoid high recurrent dislocation rates. The concept of the glenoid track and on/off-track lesions is redefining the management of bipolar bone loss. The literature is limited to level 4 and 5 evidence and better studies are required to definitively evaluate the different modalities of treatment for bone loss in shoulder instability. n Originally from New York, Dr Chiang obtained his MSc in Human Anatomy from the University of Edinburgh after his medical training. He completed his Foundation Training in the Severn Deanery and is currently a Senior House Officer in Trauma and Orthopaedics at Epsom and St Heliers NHS Hospitals and is pursuing a career in Trauma and Orthopaedics.
Correspondence Email: Cchiang@doctors.org.uk
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
Figure 5: Bipolar Bone Loss Management Algorithm *Young patients with high demand (High ISIS score), may require fixation with glenoid bone loss of 15%.
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JTO Subspecialty Section
Review of techniques and outcomes in arthroscopic shoulder stabilisation Kapil Kumar & Tauras Valevicius Recurrent instability of the shoulder is common, with an incidence of up to 90%39 following a primary traumatic anterior dislocation. Surgical attempts to address recurrent instability of the shoulder have evolved from the initial anterior soft tissue repairs1,2 or bone block procedures3,4. However, these procedures were associated with a high complication rate, with reduced external rotation and arthritis.
Bankart described reattachment of the glenoid labrum with sutures5. This is the basis of most modern techniques.
stapling7, labral reattachment with transosseous sutures8,9 and the use of rivets10. Nevertheless, even in the hands of experienced surgeons, these procedures had a high failure rate11. A survey of members of the Arthroscopy Association of North America in 1986 revealed the procedure with the highest complication rate was the anterior staple capsulorrhaphy of the shoulder12. Use of staples and transglenoid sutures were technically challenging and associated with high rates of iatrogenic injury to the articular surface and neurovascular structures. Warren designed an absorbable fixation device, which reattached the capsulo-labral complex to the anterior glenoid13.
Evolution of arthroscopic techniques
Kapil Kumar
Tauras Valevicius
With the advent of arthroscopy and development of arthroscopic surgical techniques in knee surgery, arthroscopy was adopted by shoulder surgeons. Initial use was limited to using the arthroscope diagnostically to better understand shoulder instability6. Therapeutic Arthroscopic procedures developed with capsular
Figure 1: Suretac device. Printed with permission by DM Levy30
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The advantages included avoiding metal around the join and that the implant was resorbed. It also avoided the need to drill the posterior glenoid. Although initial results were encouraging, it was associated with a high failure rate in the long term. Warner et al.11 found residual anchor material and a chronic indolent inflammatory reaction in some cases six months after surgery.
Suture anchors The development of suture anchors acted as a catalyst to the development of arthroscopic shoulder stabilisation. Anchors offer a number of advantages including multiple points of fixation, no posterior glenoid penetration, and a pull out strength comparable to sutures14. Arthroscopic stabilisation using suture anchors gives satisfactory results with recurrence rates between 5% and 8%. In a systematic review of longterm outcomes after Bankart shoulder stabilisation Harris et al. reported an 8.5% incidence of recurrent dislocation and 4% subluxations following arthroscopic surgery15, although if apprehension was included, the recurrence rate was 24% in the arthroscopic group, compared to 18% in the open group. However, Kim et al. reported recurrence rates of around 10% after both arthroscopic and open surgery, including apprehension16.
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Anchor material A variety of materials have been used for suture anchors. Metal anchors provide strong fixation, are relatively easy to insert, and are easily visualised on plain radiographs. However, they cause interference on CT or MRI scanning, and can also cause significant chondral damage if they become prominent or loose17,18. Some of these problems can be avoided by using bioabsorbable anchors. These are commonly made from polyglycolic acid (PGA) or poly-lactic acid (PLLA). Most modern bioabsorbable anchors have pull out strengths similar to metallic anchors. They are easy to revise, eventually resorb, and produce less artefact on an MRI scan. However, complications such as osteolysis, cyst formation, chondrolysis, synovitis and implant failures have been reported19. Biocomposite anchors combine traditional bioabsorbable polymer with osteoconductive calcium. As the absorbable polymer resorbs the osteoconductive calcium encourages bone to fill in. Barber et al. reported complete degradation of a biocomposite anchor used for rotator cuff repair at three years, with nearly complete or complete osteoconductivity in 50% cases40. Non-bioabsorbable and nonmetallic materials have also been used in the manufacture of bone
anchors. Polyetheretherketone (PEEK) is a chemically resistant crystalline thermoplastic. PEEK anchors are strong. They can be drilled out for revision. However, as they are radiolucent they can be difficult to localise if they dislodge and, for example, cause chondral damage.
and cartilage damage. To avoid the issues with knots, knotless anchors were developed22 and are being used increasingly.
Traditionally, labral fixation is performed using knotted sutures. Every fixation point is independent and the number of fixation points can be varied (Figure 2). Figure 3: Stabilisation using knotted anchors. Printed with permission by Arthrex
However, no clinical difference between knotted or knotless implants has been reported23. Concerns about knot loosening, possible chondral injury from knot stack and failure of fixation remain. Figure 2: Stabilisation using knotted anchors. Printed with permission by Arthrex
Boileau et al. reported that patients who had three or fewer anchors were at higher risk of recurrent instability41. Some in vitro studies suggest that horizontal mattress sutures reduce the loss of labral height20. Double loaded suture anchors have more potential to reduce laxity in capsulolabral complex, although there is no evidence of clinical benefit21. With knotted anchors there is the potential for knot laxity, knot impingement
Using bone anchors leads to concentrated point loading of the labrum at the fixation points. Osterman et al. have described the labral bridge technique24. >>
Figure 4: Labral bridge technique scheme. Printed with permission by RC Ostermann
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JTO Subspecialty Section
TRADITIONALLY, LABRAL FIXATION IS PERFORMED USING KNOTTED SUTURES. EVERY FIXATION POINT IS INDEPENDENT AND THE NUMBER OF FIXATION POINTS CAN BE VARIED. BOILEAU ET AL. REPORTED THAT PATIENTS WHO HAD THREE OR FEWER ANCHORS WERE AT HIGHER RISK OF RECURRENT INSTABILITY.OPERATION TIME AND THE USE OF ADDITIONAL EQUIPMENT.
This technique aims to provide secure fixation with uniform pressure distribution of the entire labrum. With improvement in arthroscopic techniques, attempts have been made to restore the anatomical footprint of the joint capsule and labrum. Double row or double mattress techniques have been used to fix the labrum and capsule with good results25. They are theoretically superior26, although the techniques are more technically demanding.
Bone loss Bone loss following traumatic instability of the shoulder has been reported in up to 90% of cases27. These could be on the humeral side (Hill-Sachs lesion), on the glenoid or both (bipolar). Size and location of a Hill-Sachs defect and its relation to the Glenoid track28 has been shown to be a predictor of outcome in arthroscopic labral repair29. Various techniques have been used to address humeral head bone loss including allograft, open or percutaneous disimpaction, resurfacing and hemiarthroplasty30. One of the most commonly used techniques to address bone loss on humeral side is
remplissage31. This technique aims to convert the intra-articular bone defect extra-articular by posterior capsulotenodesis, including the infraspinatus tendon, to fill the Hill-Sachs lesion. However, remplissage can limit internal and/or external rotation of the shoulder by up to 11° 32, although in athletic population return to sports has been reported in up to 96% at seven months postoperatively33.
Capsular procedures The glenohumeral joint capsule can be affected by dislocation. Increased laxity of the capsule and joint volume are important factors contributing to the stability of the joint. In multidirectional instability with significant capsular stretching or laxity, anterior or posterior capsular plication can be performed with good results35. Thermal or laser assisted36 capsule shrinkage (capsulorrhaphy) has been used. It has become less popular as there is a significant reoperation rate and high risk of chondrolysis. Use of rotator interval closure is also controversial. There is no biomechanical or clinical evidence to support its use37. However, it is still used in patients with hyperlaxity, and
some authors recommend it as a treatment of choice in non-traumatic anterior shoulder instability38.
Conclusion In conclusion, arthroscopic techniques to address recurrent instability of the shoulder continue to evolve. Advances in suture anchors and suture materials have improved the outcomes following arthroscopic stabilisation for recurrent traumatic instability of the shoulder. n Kapil Kumar is an Orthopaedic Surgeon with a special interest in Shoulder and Elbow Surgery in Aberdeen. His areas of clinical research include shoulder arthroplasty, shoulder instability and PRP in management of tendinopathies. He has been a Training Programme Director for Trauma and Orthopaedics in North of Scotland. Tauras Valevicius trained in Lithuania and is currently working as an advanced shoulder fellow at Woodend Hospital in Aberdeen. He is interested in shoulder instability.
Correspondence Email: kapilkumar@nhs.net
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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In Memoriam
Michael Heywood-Waddington 24th April 1929 - 17th February 2016 Michael Heywood-Waddington died last year aged 86. He was a Consultant Orthopaedic and Trauma surgeon at Broomfield, Chelmsford and Black Notley Hospitals from 1967-1992. Born in Littlehampton to a medical family he attended Epsom School. He was awarded a scholarship to St John’s College Cambridge to read medicine; his clinical studies were at The Middlesex Hospital with Ernie Kirwan. After house jobs he went to Jamaica studying under Sir John Golding in 1956 he was involved in treating polio victims’ disabilities. Michael Heywood-Waddington
Mike did his National Service in Iraq where he became Chief
Medical Officer at the RAF base in Habbanya looking after 10,000 personnel. He returned to the UK and trained under Sir Herbert Seddon at the RNOH and Norman Capener in Exeter. He was one of the first orthopaedic surgeons performing total hip arthroplasty under Ken McKee. Mike was said to be the first orthopaedic surgeon to perform total hip arthroplasty in Belgium, Greece and Kent. An advocate of the posterior approach to the hip (without trochanteric osteotomy) he was involved in a heated argument with Sir John Charnley. Mike was vindicated in the long-term (over 30 years) follow-up of his operations, which demonstrated excellent
results. Mike was instrumental in organising the orthopaedic training rotation in East Anglia. Following his retirement he pursued a busy medico-legal practice. Mike was a true polymath and had a lifetime interest in cricket, skiing, photography and steam engines. He was a great raconteur of his many adventures. Mike suffered a heart attack in his fifties; following surgery he was able to continue until retirement. Sadly his final illness robbed him of his faculties and he died peacefully. Mike leaves his devoted wife Virginia and son John.
Barry Fearn
4th March 1934 - 2nd November 2016
Barry Fearn
Barry Fearn was educated at Shrewsbury School, Cambridge and St Mary’s Hospital. During his National Service he was a Medical Officer in the Royal Irish Fusiliers in Germany. He was later seconded to Khartoum for a year. His surgical training was largely at the Nuffield Orthopaedic Centre in Oxford which he considered the Mecca for an aspiring orthopaedic surgeon. He was appointed Consultant in 1972, one of three orthopaedic surgeons in Brighton and one of two in Cuckfield where Frank Horan was his colleague for over twenty years. Barry was on call in both Brighton and Cuckfield and maintained this heavy burden for many years. He was heavily involved in the development of trauma and orthopaedics, especially in Brighton. He became very interested in teaching on the South East Thames Orthopaedic Training Programme. Many
orthopaedic surgeons both in the UK and abroad were trained by Barry including foreign Ministers of Health! At various times he was Surgeon to both Brighton and Hove Albion Football Club and Sussex County Cricket Club. He had rowed for his school and college at Cambridge and kept up this interest over many years and also played a significant part in the Territorial Army for which he received the Territorial Decoration. He had an encyclopaedic knowledge outside medicine. His greatest love was opera and he was an enthusiastic supporter of Glyndebourne and the Christie family over many decades. He was a kind and generous man who will be remembered with affection by both his colleagues and his patients. He leaves his wife, Gay, four children and ten grandchildren.
Remember them fondly It is with great sadness that we report the passing of the following members. Our thoughts are with their families and friends at this time. Iain Duff Peris Edwards James Hay Geoffrey Illingworth Adam Johns
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Imprint
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