In our Features section you will find articles that
focus on research, training, regional spinal networks
and responses from our Specialist Societies about
innovations in their subspecialty
Features
––– Pages 24-55
Read the News and
Updates section for
the latest from the
BOA and beyond
News & Updates
––– Pages 02-23
Inside
For the latest update on our clinical
issues, see our Peer-Reviewed Articles;
the focus of this issue is innovation,
plus our regular “How I…” piece
Peer-Reviewed Articles
––– Pages 56-68
THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 01
JTO News and Updates
JTO News and Updates
02–23
JTO Features
24–55
Why Opt In?
24
Inspiring the best to be better: The BOA Clinical
Leadership Programme
26
Regional Spinal Networks
27
From CT scan of a bone to 3D printed model, using
Open Source software and a desktop printer
26
Hip Fracture Research: The WHiTE study and beyond 32
What’s your innovation?: From our Specialist Societies 34
New Guidelines for Diabetic Feet
36
Care Quality Commission (CQC) Inspections
38
Self-Perception in Orthopaedic Trainees: Is there
a Gender Difference?
40
Variability in Trauma and Orthopaedic Training
Programmes: Two perspectives
42
Incorporating leadership and professional skills
training into a T&O regional teaching programme
50
The Importance of Recognising the Different Kinds
of Expert Surgical Evidence
52
JTO Peer-Reviewed Articles 56–68
Innovations in Trauma and Orthopaedic Surgery:
3D Printing
56
Advances in osteoarthritis imaging: What will make
it into clinical practice?
60
The use of stem cells in articular cartilage defects:
Where are we now?
64
How I… fix a Monteggia variant injury with a radial
head fracture
68
In Memoriam
69
General information
and instructions for authors
72
Contents
From the
Editor
So, two years as JTO Editor
have flown by, as I step into my
presidential role, Phil Turner will
take over and continue, I am sure,
to move things ever onwards and
upwards.
I have to say a huge thank you
to Lauren, Emma and the two
deputies I have had – Ananda, and
now Fred. It is true they do all the
hard editorial work, but really it is
the contributors who put in the
hours and give us the opportunity
to discuss very publicly so many
professional issues that need
to get into black and white. We
have a great relationship with our
publishers and we are exploring
the potential for a JTO app. This
will give us an opportunity to
reach a wider audience and make
the JTO more accessible for our
current membership.
You only have to look at the
range of subjects discussed in
this issue and in particular look
at the sections on innovation
(pages 34-35 and pages 56-67)
to see that we as a profession
are fully engaged with driving
our professional lives and patient
care forward.
Focusing on the future does
challenge us to consider what
innovations are going to be
made that will change our
clinical care over future years.
A major issue is how innovation
and change can be controlled
but not inhibited; it will be
the biggest question over the
next few years, this will take
leadership. Trying to develop
leaders for the future is clearly
something the BOA has taken
on board. It is so much
better to develop leaders
taking into account
their natural talents
than to let Napoleonic
diminutive rotund
megalomaniacs take
over...
Finally, we have letters
(page 20)! The caption
competition winner
(page 17) was for me
a special moment as
I have been mistaken
for Des Lynam on
many occasions
which just helps to
reinforce my belief
that despite all the
evidence to the
contrary I am 6ft.
4in tall (see above).
Ian Winson, BOA Vice President
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 02
JTO News and Updates
My year at the BOA helm
Tim Wilton, BOA President
It has been a busy and rather
surprising year at the BOA
helm! First of all I would like to
thank you all for the wonderful
opportunity I have had to lead the
organisation over the past year. I
have enjoyed it immensely despite
the undoubted rigours involved
from time to time. I am looking
forward to the chance to meet up
with and speak to as many of you
as possible at the Congress in
Belfast. I have greatly enjoyed the
chance to have direct contact with
so many of you at the Specialist
Society meetings I have managed
to attend. Our relationships with
the various Specialist Societies
have, I think, never been better
and it is certainly a major priority
for the BOA that they should
remain so.
There have been many challenges
during the year, and some
unfortunately remain unresolved.
The junior doctors dispute with
government has been a huge
issue and I hope you agree the
BOA has supported our trainees
steadfastly throughout. The
imposition of a new contract
which causes any of the juniors
to earn less seems to me a
huge error of judgement when
seen against a backdrop of the
enormous debts they all now carry
into their working lives. Our own
solution to the problem of morale
amongst trainees must surely be
to work hard to ensure their time
spent training is never wasted.
Clearly one good way to avoid
being caught out by events is to
expect the unexpected…or at
any rate the unlikely. This is easy
to say and not always simple to
do but those of you who were
able to read my first Presidential
article last year may recall that
I predicted a fairly torrid and
eventful year. Nonetheless, I
wonder just how many of us
would have predicted that we
would be the first to EXIT with
all the talk there had been of
GREXIT the year before.
Closer to home but in parallel
we in trauma and orthopaedics
have unfortunately been faced
with not one, but two separate
‘annual’ attacks on Tariff within
just four months. In March the
threat was made very forcefully
that we would be subject to
substantial reductions in Tariff
for orthopaedics from April
2016, only to have the threat
lifted at the last minute and the
‘old Tariff’ continued despite its
acknowledged short-comings.
This was not because NHS
England wished to go on paying
the same price for our work, but
simply because they thought
at that time it would be “too
disruptive to make such major
changes across the board”
by the introduction of the new
HRG4+ system.
We did, therefore, anticipate that
this change was waiting in the
wings to be introduced next year.
What we did NOT anticipate was
that NHSI (Ex Monitor) would
see fit to stack all the potential
weapons in a row and fire them
at orthopaedics; as a volley!
The dust had barely settled
when in July this year we
were informed that a new
Tariff based on HRG4+ would
indeed be introduced from
April 2017, but would be
accompanied by swingeing
cuts in Tariff which would
amount to 19% reductions
for trauma and orthopaedics.
Tim Wilton
This announcement, planned
to be made just days before
the summer recess, was
made up of a 10% ‘efÏciency
saving’ across all specialities,
another 2% adjustment which
they cannot really explain but
relates to overuse of ‘specialist
commissioning’ and then a 7%
additional cut because trauma
and orthopaedics has allegedly
been ‘overfunded’ for about
seven years since the waiting list
push was supposed to end.
You will be pleased to hear that
our immediate and energetic
interventions lead to an urgent
review and step-back from the
edge by the NHSI team. You
may be slightly less reassured
to hear that they then agreed to
reduce the planned reduction in
Tariff from 19% to 11.5%, which
is still hugely worse than most
Trusts think they can possibly
manage. We will persevere with
negotiations!
Waiting lists have come down
dramatically and have largely
stayed down in much, but not
all, of the country. However,
that is due in no small part to
the large number of elective
cases being done on extra
lists at weekends and/or being
transferred to the Independent
Sector, both of which have the
potential to disappear overnight
if the finances do not stack up
for the hospitals.
The waiting-times for “elective”
surgery have always been
volatile which is due largely to
the erroneous view that this
sort of surgery is a luxury. Our
patients awaiting surgery for
painful hips and other disabling
conditions are unlikely to agree
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 03
with that view, but they remain the
target whenever a government
wishes to reduce expenditure in
the NHS because they are less
politically emotive than other
groups such as paediatrics,
cancer patients, heart disease etc.
As a profession we must continue
to lead the charge in pressing
for proper access to appropriate
treatment for our patients.
Currently in much of Canada
financial constraints have led to
waiting times very similar to those
in England 10-15 years ago and
there are still, or already, pockets
of similarly poor access in the
UK. BREXIT and the ensuing
financial strictures are likely to be
used by politicians as an excuse
to tighten the financial screws on
the NHS still further. It will have to
be made clear to ministers that if
the funding is cut severely, as they
suggest; a return to waiting lists of
over a year is highly likely and will
be directly attributable to these
actions by them.
While we will continue to support
making savings where they are
clinically appropriate and using
cheaper devices in our work
where they produce equivalent or
better outcomes for the patients,
our priority has to be to ensure
and improve quality of care rather
than to reduce costs if these two
aims are not coincident.
To my mind this principle applies
across the whole spectrum of
orthopaedics and is perhaps the
one guiding principle that we can
and must retain if we want to
maintain a first class trauma and
orthopaedic service for ourselves
as well as our patients.
There is some light along the
tunnel. Our first and very urgent
response to NHSI about Tariff
in July resulted in a re-think
and a delay in publishing their
plans. Regarding BREXIT, the
EFORT hierarchy with whom I
met in July feel there is no reason
why BREXIT should have any
adverse impact on our dealings
with them and they are keen to
press ahead with various plans
we have jointly concerning
implant safety, training standards,
and such matters as mutually-
agreed European guidelines for
some orthopaedic conditions.
NICE have decided to take a
completely fresh look at VTE
prophylaxis, and came to see us
this week to consult us about our
issues with their current advice…
perhaps a breakthrough!
Our trauma community goes
from strength to strength, with
BOA hip fracture service reviews
in demand. Please rest assured
that the income stream from this
activity is used to fund BOAST
production and dissemination,
as well as the annual training
day (featured on page 14). The
OTS meeting in Warwick earlier
in the year was a particular
success, reflecting a strength in
depth in orthopaedic, as well as
orthoplastic, trauma.
Orthopaedics has some of
the most effective, and cost-
effective, treatments available in
medicine and in the UK we have
increasingly good information
about what works, how we are
doing and when and how to
intervene to get the best results.
The outcomes data from the
Registries give an excellent
tool to help us to do our jobs
better. ODEP ratings now
extend to knees, and we have
the potential with the Beyond
Compliance scheme to get far
better information about implants
in the early phase of their use.
We can get first class cost-
effectiveness data for much more
of our interventions if we take
the emerging registries seriously
and raise compliance with them
as quickly as possible. Then we
will really have data which can
effectively counter the pressures
to limit what we offer patients.
I do have concerns that I have
not managed to ‘sort’ all of these
issues to my satisfaction before
Ian Winson takes over as BOA
President. On the other hand,
there is no doubt that he is
more than up to the job: he has
been an outstanding and hugely
supportive Vice-President to me
over the last year and he will be a
great success as President in the
coming year. I would like you all
to welcome him to the Presidency
with the enthusiasm he deserves
and to offer him any and all
assistance in the coming year so
that he may carry out his duties
with the energy and wisdom of
which I know he is capable.
Well this should be interesting.
Two years ago when I joined
the Presidential line we had a
debate as to where the curse
“may you live in interesting times”
came from. Often known as
the Chinese curse, the nearest
actual translation of the Chinese
saying is “better to be a dog in a
peaceful time than a human in a
chaotic period”. I guess, looking
around at medical, national and
international politics, it doesn’t
get much more chaotic than this.
Then again, 100 years ago the
world was in the grip of the First
World War so maybe we should
not overstate the case. But it
does illustrate how important it is
to check your data!
The BOA as an organisation
has developed, not only to be
reactive, but to be proactive, and
during my period as President we
will continue to look to the future.
We have really established the
principle that for MSK patients
it is actually important to have
a dialogue with orthopaedic
surgeons along with those
other professionals involved in
their care. As clinicians we are
encouraged to reflect on our
practices, as President I think
it is important I operate to the
other definition of reflection
and reflect your views on how
we move forward. I do have
my own views of what has
made this happen in the past;
Quality and Innovation, hence
my theme for the year and for
the Congress in a year’s time.
Wish us all luck!
Ian Winson
You just keep going!
Ian Winson, Incoming President 2016-2018
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 04
JTO News and Updates
The BOA honours
outstanding members
Frank Burke trained and
graduated in Newcastle and
completed orthopaedic training
in Oswestry with six-month
hand surgery fellowships in
Derby, Louisville and Iowa
City. He was appointed a hand
surgeon in Derby in 1978 and
Professor of Hand Surgery in
July 1996. Frank developed a
Diploma of Hand Therapy and,
with others, the Hand Society
Manchester Instructional
Courses and was the external
assessor for the Hand Society’s
Diploma in Hand Surgery.
He is currently archivist of
the International Federation
and was awarded the title of
Pioneer in Hand Surgery. The
Derby Hand Surgery Service
is currently staffed by nine
full-time hand surgeons drawn
from plastic surgery and
orthopaedics.
The BOA is pleased to announce the recipients of the 2016 Honorary Fellowships,
which will be presented at the Annual Congress in Belfast.
Frank Burke
Stephen Cannon MBE
Charles Court-Brown
Ian Ritchie
A native of Sheffield, Stephen Cannon
studied medicine at Trinity College
Cambridge and Middlesex Hospital
qualifying in 1974. He commenced a
surgical career, initially in obstetrics,
and after junior posts in other surgical
specialties gained FRCS in 1978. He
returned to the surgical rotation at
Middlesex Hospital which incorporated
exposure to orthopaedics with Rodney
Sweetnam and Michael Edgar. He
was appointed Senior Registrar
on the Middlesex/Royal National
Orthopaedic Hospital rotation in 1981
and soon developed an interest in
musculoskeletal oncology and knee
surgery. Stephen was fortunate to be
exposed to some of the world leaders
in orthopaedics at that time particularly
by working with George Bentley, Tony
Catterall and the late Lorden Trickey.
He went to the US as a Johnson and
Johnson Fellow and was appointed to
the RNOH as consultant in 1988. He
has developed, with his colleagues,
both the Bone and Soft Tissue Tumour
Unit and the Joint Reconstruction
Unit at Stanmore which work closely
to the Biomechanical Engineering
Dept. of University College London.
Stephen was awarded MBE in 2016.
Charles Court-Brown graduated
with a BSc in Zoology from
Aberdeen and an MBChB
from Edinburgh. His surgical
training was in Edinburgh with
a Spinal fellowship in Toronto
in 1984/85 in a Level I Trauma
Centre. He was very impressed
by the non-British approach
to trauma and returned to
Edinburgh as Senior Lecturer
with a major interest in trauma.
He contributed to much of the
early work on tibial intramedullary
nailing and then worked with
Margaret McQueen studying
the treatment and outcomes of
the common fractures. Charles
also developed a major interest
in open fractures and helped
Edinburgh become one of the
first orthoplastic units in the UK.
In the mid-1990s, Charles realised
that fracture epidemiology was
easily studied in Edinburgh as
there was only one hospital
treating trauma. Since then he
has concentrated mainly on
epidemiology, social deprivation
and fractures in the elderly.
Ian Ritchie was a DGH Trauma
and Orthopaedic surgeon in
Forth Valley, Central Scotland
for 24 years. During that
time his practice was in the
generality of T&O with an
interest in the upper limb.
Other interests included
surgical training and education.
He was on the AO Faculty for
the Principles Course for a
number of years. He convened
Training the Trainer courses
for RCSEd both in the UK and
internationally. In 2000, he
was elected to the Council of
the College. Ian was Director
of Surgical Training at the
College from 2005 to 2009
when he was elected Vice
President. He was elected
President of the College
from 2012-2015. He now
leads the development of the
RCSEd International Surgical
Fellowship Programme to
support International surgeons
who wish to come to the UK
for up to two years to enhance
their skills and understanding
in a surgical discipline.
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 06
JTO News and Updates
BOA Latest News
Queen’s Birthday
Honours
The BOA is delighted to announce
that Past President, Stephen Cannon,
was appointed a Member of the British
Empire in the Queen’s Birthday Honours.
Mr Cannon has made such a strong
contribution to trauma and orthopaedics
- both nationally and in Europe and we
are proud that his work with the Skeletal
Cancer Action Trust is getting the profile it
so very much deserves. Congratulations,
Steve – a much-deserved honour!
Orthopodcast:
Episode 8
If a peer or a more senior colleague is doing
surgery for which there is no evidence, what
would or should you do?
The drive for professional recognition puts
tremendous pressure on surgeons to engage in
questionable practices… who and how should
we illuminate these?
In ‘Surgery: the ultimate placebo’, Professor
Ian Harris, an Australian orthopaedic surgeon
and academic, provides us with a view
that some surgery may be ineffective, or
as effective as placebo. Much has been
written recently about ineffectiveness and
overtreatment in modern medicine; Professor
Harris links this with the topic of placebos, and
applies it to surgery.
This 15-minute orthopodcast interview with
the author explores how to stop the surgical
malaise of ignoring good science and how
to handle the situation when faced with such
ignorance www.boa.ac.uk/orthopodcast/
episode-8-surgery-ultimate-placebo.
BOA Instructional Course 2017
We are pleased to announce that the 2017 BOA Instructional Course, being held on
7th-8th January, will focus on spine and trauma. Delegates will have an opportunity to
gain a number of clinical case-based discussions (CBDs) in the physiology of trauma,
complications of inflammatory spine conditions and immediate assessment, care and
referral of spine trauma. The Instructional Course is a highlight of the BOA’s training and
education calendar, bringing together T&O trainees at all stages of their postgraduate
training to prepare for their FRCS examination. Registration is now open, but please note
that places are limited so we would encourage you to apply as soon as possible - visit
the BOA website for further details: www.boa.ac.uk/events/instructional-course.
BOA Screencast: Assessing casting
techniques for surgical trainees
The latest BOA screencast is available on our website and is on the topic of ‘Assessing casting
techniques for surgical trainees’. Casts applied by surgeons could be better; the traditional
approach to training in the art of casting has been inadequate and British Casting Certificate
holders are encouraged to engage with surgical training and assessment. The BOA has created a
10 minute screencast for holders of the BCC and T&O trainees, aimed at collaboration between the
two groups to drive up standards of casting in the UK. Viewers are briefed about how best to use
the T&O curriculum and one of the ISCP workplace based assessments to structure learning and
assessment. Please visit www.boa.ac.uk/training-education/orthopodcasts to view the screencast.
BOA NICE-accredited
Commissioning Guides
At the beginning of August, the BOA
opened a one-month public consultation
as part of a review process for four of
its NICE-accredited commissioning
guides. Consultation responses are
now being reviewed and the guides will
be reissued before the end of the year.
We would like to take this opportunity
to thank all who responded to any or all
of the consultations.
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 07
For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.
We would like to thank and
congratulate Yusuf Mirza and
Shiv Sha for participating
and completing the British
10K London Run on Sunday
10th July and for reaching
their fundraising targets.
Huge thanks also to Edmund
Ieong for taking part in the
RideLondon-Surrey 46 on
Sunday 31st July. This
year is the first year that we
have had these sought after
places available.
If you are interested in
participating in either of
these events (or the London
Marathon) in 2017, contact
jointaction@boa.ac.uk.
Scaling Up Improvement
The BOA has partnered with Northumbria Healthcare and the Royal
College of Physicians to run a quality improvement collaborative for
patients with a hip fracture. The initiative is funded by the Health
Foundation’s “Scaling up” programme for £500K and will bring together six
acute hospitals aiming to improve care and mortality by a multidisciplinary
approach. The programme launched on 6th September 2016 and will run
for two years. For more information, please contact policy@boa.ac.uk.
BOA Appointments
It is our pleasure to announce the following appointments to
key positions:
l BOA President for 2018/19: Phil Turner
l BOA Honorary Secretary for 2017-2019: Deborah Eastwood
l BOA Trustees for 2017-2019: Mark Bowditch, Lee Breakwell,
Simon Hodkinson, Richard Parkinson
BOA
Travelling
Fellowships
We are pleased to offer
a number of Travelling
Fellowships to our members
for 2017. Fellowships offer
a unique opportunity for
members to visit centres of
excellence overseas, gaining
invaluable knowledge,
experience and different
cultural perspectives within
trauma and orthopaedic
surgery. Up to 20
fellowships will be available.
Applications will open on
13th September 2016.
For further information,
please visit www.boa.ac.uk/
training-education/boa-
travelling-fellowships.
BOA Clinical
Leadership
Programme
The BOA Clinical Leadership Programme
(CLP) is an excellent opportunity to provide
fellows with the support to develop their
leadership capability whilst offering insights
into how to accelerate service transformation
and quality improvement within their given
speciality. The programme consists of four
two-day modules which focus on leadership
effectiveness, context for improvement
within T&O and the tools and methodology
to support this, culminating in fellows
presenting their improvement project as
posters at the BOA Congress. Currently,
there are three routes to apply, either
individually, through your trust or via a
specialist society sponsoring the programme.
Applications open in autumn 2016 with further
information available on the BOA website
www.boa.ac.uk/training-education/clp.
BOA Collaborating with NHS Right Care
The BOA is pleased to announce that we have agreed to collaborate with NHS Right Care in their initial roll out of ‘hands-on’ support to
CCGs across the country. Specifically, we will be linking together our network of Clinical Champions, recruited by the BOA to engage with
commissioners at a local level, with Right Care’s ‘delivery partners’, who will be providing direct support to CCGs to redesign local care pathways.
NHS Right Care is a programme designed to increase value in healthcare by reducing unwarranted variation. The programme uses the NHS
Atlas of Variation and Commissioning for Value Packs to enable commissioners to compare, for example, hip and knee replacement rates to their
peers. Following this comparison, Right Care supports commissioners to work with local clinicians and managers to establish whether variation is
unwarranted and, if so, develop a plan to reduce the unwarranted variation.
Joint Action
Challenge Events
Volume 04 / Issue 03 / September 2016 boa.ac.uk
Page 08
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