Volume 08 | Issue 02 | June 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk
Journal of
Trauma and
Orthopaedics
Non-accidental injury in
children during COVID-19 p14
Training in orthopaedics:
The show must go on p12
COVID-19: My experience
of testing positive p16
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JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 01
3 From the Executive Editor
Bob Handley
5 From the President:
Working together – the way forward
Don McBride
6-10 Latest News
12 Training in orthopaedics:
The show must go on
Morgan Bailey, Sabina Barbur,
Daniel Cadoux-Hudson,
Rishi Das and Daniel Marsland
14 Non-accidental injury in children in
the time of COVID-19 pandemic
Emily Baird
16 Coronavirus (COVID-19):
My experience of testing positive
Kathryn S S Dayananda
18 An orthopaedic surgeon’s diary at
the Nightingale Critical Care Unit
Niall Eames
22 Orthopaedic care changes since the
B.C. (Before COVID-19) time period
Mary Campbell, Andrew Hughes,
Brendan Daly, Aedín Hanahoe,
Darren Moloney, Iain Feeley,
Eoin Sheehan and Khalid Merghani
26 Commentary on
the Swansea Hip
interrogation Fracture
Tool (SHiFT)
Michael Cronin,
Mark Mullins,
Praveen Pathmanaban,
Paul Williams and Matthew Dodd
28 COVID-19 causes a SHiFT in
the sands for proximal femoral
fracture management?
Michael Cronin, Mark Mullins,
Praveen Pathmanaban,
Paul Williams and Matthew Dodd
32 A letter in response to: COVID-19
causes a SHiFT in the sands for
proximal femoral fracture
management? A plea for caution
Peter M Lewis, Miriam Day,
Lisa A Williams, Laura Lougher,
Glenn J Clewer and Stephen Sarasin
34 A response to the letter by Lewis et al.
from the authors of: COVID-19 causes
a SHiFT in the sands for proximal
femoral fracture management?
Michael Cronin, Mark Mullins,
Praveen Pathmanaban,
Paul Williams and Matthew Dodd
37 In Memoriam:
John Seddon Hopkins,
Anthony John Hall
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In this issue...
Contents
16
Journal of
Trauma and
Orthopaedics
We are committed to sustainable forest management and this publication is printed by Buxton
Press who are certified to ISO14001:2015 Standards (Environmental Management System).
Buxton prints only with 100% vegetable based inks and uses alcohol free printing solutions,
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69%
Bone cement with
gentamicin and clindamycin69
* Sprowson AP et al. Bone Joint J 2016; 98-B: 1534–1541
reduction of
deep infections in
hip hemiarthroplasty after
fractured neck of femur *
JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 03
From the Executive Editor
Bob Handley
trange and strained times. Writing an editorial that will be
read a few weeks later is always risky business but even more so
when surrounded by such volatility. It is, however, the essence
of so much of what we do; we make the best judgement we can
in the circumstances that prevail and proceed. Whether those
circumstances be a tricky problem in theatre or the fallout from a
pandemic we carry on. This special edition of the JTO charts some of our efforts.
The normal printed JTO had been cancelled but then an opportunity
arose to partially resurrect it as special on-line PDF version. To keep up with
the ever changing world of COVID-19 we had already started publishing articles
in a rapid turn-around Journal called the TJTO&C or the Transient Journal of
Trauma Orthopaedics and the Coronavirus. This PDF version of JTO is in the
main a compilation of those articles, with some updates and commentaries.
The swing in the pervading mood over the last eight weeks has been
extraordinary; an acute fear of being overwhelmed by pandemic respiratory failure
morphing into a pervasive threat of endemic Coronavirus. The articles we have
chosen reflect this mood swing. Some document the redeployment and experiences
of individuals in the acute phase. ‘An orthopaedic surgeon’s diary at the Nightingale
Critical Care Unit’ page 18 will be read in the future in a way similar to how I heard
my parents describe the Blitz. A personal story of ‘Coronavirus (COVID-19): My
experience of testing positive’ page 16 will hopefully soon seem like a relic of a
bygone age. They are a record of what happened, a Pepys diary of 2020.
There are more philosophical issues that arose. The article that promoted
the most debate was that detailing SHiFT, a potential response to the anticipated
collapse in resources which threatened. What would be the consequences of this
on managing our normal urgencies, the exemplar for T&O being the hip fracture.
It confronts triage of a condition with a risk of mortality, which for most of us
has only ever been role play. We did it on our ATLS course but there was now
the prospect of it happening for real. The Armageddon that was feared did not
materialise but chronicling the planning exercise is of value.
The acute loss of resource may now be replaced by a chronic one. With
a morass of unpredictability awaiting; slower operating, fewer beds, PPE, staff
testing, patient testing, consent, residual fear, the list could go on. This continues to
generate noise in the unending health dilemma of whether we need central diktat or
local solutions; one with its inflexibility the other risking a postcode lottery.
A full retrospective can be had in a future bumper edition of JTO or a
component of a Congress, but we have no idea when. Until then the TJTO&C
will provide a forum.
It is now customary to sign off with the invitation or encouragement
to keep safe, the inference often being to hunker down to stay alive. I like the
adage that “Life is movement and movement is life.” I don’t think that this
was intended to apply only to the muscles used in breathing. In T&O our most
common objective is restoration of function, this should now be the objective for
both society and the individual. Phase one of COVID-19 could be summed up as
“Be safe, don’t do anything” now we need “Do something but safely!”
Those could just be hollow words but what better example could we have
of the benefits of restoring function than Sir Tom. The raw statistics don’t look
that good for a man in his late 90s with a hip fracture, but a broad smile and
£33 million for the NHS is quite a result. We salute you Sir! n
Cover image courtesy of Mike Dawson: Painting of Captain Sir Tom Moore.
JTO Editorial Team
l
Bob Handley (Executive Editor)
l
Rhidian Morgan-Jones (Editor)
l
David Warwick (Medico-Legal Editor)
l
Tricia Campbell (Trainee Section Editor)
BOA Executive
l
Don McBride
(President)
l
Phil Turner
(Immediate Past President)
l
Bob Handley
(Vice President)
l
John Skinner
(Vice President Elect)
(Honorary Treasurer)
l
Simon Hodkinson
(Honorary Secretary)
l
Deborah Eastwood
BOA Elected Trustees
l
Don McBride (President)
l
Phil Turner
(Immediate Past President)
l
Bob Handley (Vice President)
l
John Skinner
(Vice President Elect)
(Honorary Treasurer)
l
Simon Hodkinson
(Honorary Secretary)
l
Deborah Eastwood
l
Colin Esler
l
Peter Giannoudis
l
Grey Giddins
l
Robert Gregory
l
Anthony Hui
l
Andrew Manktelow
l
Ian McNab
l
Fergal Monsell
l
Rhidian Morgan-Jones
l
Hamish Simpson
l
Arthur Stephen
l
Duncan Tennent
BOA Staff
Executive Office
Chief Operating Officer
- Justine Clarke
Personal Assistant to the Executive
- Celia Jones
Education Advisor
- Lisa Hadfield-Law
Policy and Programmes
Director of Policy and Programmes
- Julia Trusler
Programmes and Committees Officer
- Harriet Wollaston
Educational Programmes Assistant
- Eliza Khalid
Communications and Operations
Director of Communications and Operations
- Emma Storey
Interim Director of Communications
and Marketing
- Annette Heninger
Marketing and Communications Officer
- Sabrina Nicholson
Membership and Governance Officer
- Natasha Wainwright
Education and Online Exam Project Manager
- May Elphinstone
Publications and Web Officer
- Nick Dunwell
Finance
Director of Finance - Liz Fry
Deputy Finance Manager - Megan Gray
Finance Assistant - Hayley Oliver
Events and Specialist Societies
Head of Events - Charlie Silva
Events Administrator - Venease Morgan
Exhibitions and Sponsorship Coordinator
- Emily Farman
UKSSB Executive Assistant - Henry Dodds
Copyright
Copyright© 2020 by the BOA. Unless stated otherwise, copyright rests with the BOA.
Published on behalf of the British Orthopaedic Association by: Open Box M&C
Advertising
All advertisements are subject to approval by the BOA Executive Board. If you’d like to
advertise in future issues of the JTO, please contact the following for more information:
Open Box M&C, Regent Court, 68 Caroline Street, Birmingham B3 1UG
Email: inside@ob-mc.co.uk | Telephone: +44 (0)121 200 7820
Disclaimer
The articles and advertisements in this publication are the responsibility of the contributor
or advertiser concerned. The publishers and editor and their respective employees,
ofÏcers and agents accept no liability whatsoever for the consequences of any inaccurate
or misleading data, opinions or statement or of any action taken as a result of any article
in this publication.
BOA contact details
The British Orthopaedic Association, 35-43 Lincoln’s Inn Fields, London WC2A 3PE
Telephone: 020 7405 6507
Credits
ur cover image for this issue of JTO
is a painting of Captain Sir Thomas
Moore, who has captured the
hearts of the nation during the COVID-19
pandemic and become Britain’s greatest-
ever fundraiser. The painting by Elstree-
based artist Mike Dawson was donated to
Watford General Hospital.
Former British soldier Captain Tom,
who reached the milestone of his 100th
birthday on Thursday 30 April, took on
the challenge of walking 100 laps of his
25-metre garden in Bedfordshire. His
initial aim was to raise £1,000 for NHS
Charities Together as a ‘thank you’ to the
staff who had helped him recover from
cancer and a broken hip. When his walk
generated media interest, hundreds of
thousands of people from all over the world
began to contribute to his fund. By the
time his fundraising campaign had closed
he had raised in excess of £33 million!
In recognition of Captain Tom’s
extraordinary fundraising efforts, his
hundredth birthday was marked in a
number of ways, including flypasts by the
Royal Air Force and the British Army. He
received over 150,000 cards, and was
appointed as honorary colonel of the Army
Foundation College and his knighthood was
announced on 19 May.
Mike Dawson, who specialises in ‘pop art’,
painted Captain Tom wearing his blazer
and medals, backed by the NHS rainbow.
Mike said: “Like everyone else, I’ve been
fascinated by Captain Tom’s story and I’ve
been hugely impressed by his pluck, his
humility and his charm. He’s been a breath
of fresh air and he’s lifted the nation’s spirits.
It’s an honour to paint him and I’m delighted
that the wonderful staff at Watford General
Hospital are happy to receive the end result.”
Images and videos of Mike’s paintings can be
seen on Facebook.com/MikeDawsonArt or
mike.dawson.art.
Story of the front cover
Credits
Leave a lasting legacy
Whether you’re someone who is suffering from a musculoskeletal
disorder or whether your life’s work is helping those who are
suffering; you can really make a difference.
Once you have considered your immediate friends and family;
please consider leaving a life-changing gift to Joint Action to fund
ground-breaking orthopaedic research.
Your donations support the BOA Orthopaedic Surgery Research
Centre (BOSRC), based at York Trials Unit, which works with the
BOA in expanding the number of trials in the UK related to Trauma
and Orthopaedics.
Your generous donations are helping us to advance Trauma
and Orthopaedic research. Thank you very much!
Remembering a charity in your Will is simple. For an
easy step-by-step guide to everything you need to know
about leaving a legacy to Joint Action, please visit
https://www.boa.ac.uk/research/joint-action-
the-orthopaedic-research-appeal.html.
JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 05
Working together – the way forward
Don McBride
hen writing my last JTO Presidential article for the March
edition, plans were coming along very nicely for the Annual
Congress in Birmingham and the visits to the American
Academy of Orthopaedic Surgeons, Canadian Orthopaedic
Association, American Orthopaedic Association and South
African Orthopaedic Association meetings were all organised. The February Council
and Executive meetings had been completed fairly uneventfully and then ‘all hell
let loose’. COVID-19 arrived in Europe catastrophically affecting Italy and Spain
then sweeping towards the UK. Lockdown ensued with variable political responses
across the globe. Gradually, all meetings were initially postponed but then cancelled
including, unfortunately, our own in its normal form. However, a number of
societies have organised alternatives including webinars, instructional
lectures and educational events. We are currently looking at these
alternatives both before and at the time of the proposed Congress
in September. Keep those dates free and watch out for updates.
My theme for this year’s Congress was ’Working
Together – the Way Forward’. In the wake of the pandemic
I do not believe that you could find a better term for the
incredible response of the Trauma and Orthopaedic community
in the UK. From the very outset the BOA have provided
regularly updated information online on a wide range of topics
with support and input from many specialist societies and
individuals across the membership. (This work has been
very well received by our members and links to the various
resources can be found on page 08). The BOA has worked
with NHS England, the Royal Colleges, Public Health
England and other groups including GIRFT contributing
to and assisting with their own updates, for example,
on PPE. However, what has been most evident is our
members’ fantastic efforts, resilience and ability to adapt
to the necessary changes in our working environment to
ultimately protect the welfare of our patients. This shall,
I am sure, be maintained throughout the pandemic and
when it ends whenever exactly that might be.
I should like to finish by thanking the BOA staff
who have responded magnificently to the difÏculties,
which have occurred during this time. Their hard work
and flexibility have been exemplary. n
From the President
As we left Australia and New Zealand in October 2019
I said to my better half – “this is only the start of
an exciting year ahead”. Little did I know how
right I was but clearly not in the way I expected.
The latter part of 2019 and early 2020 were
completed in a fairly straightforward manner and
even a few murmurings about Wuhan in China
from December onwards did not initially, at least,
register that a potentially catastrophic global
event was about to ensue.
06 | JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk
Latest News
The BOA has been very busy producing guidance documents and articles throughout the
COVID-19 pandemic, working with the Colleges and NHS bodies to ensure patients and
surgeons are supported during these unprecedented times. We highlight some of the recent
work we have been doing here. We are very grateful to those who have committed time to
helping the BOA with this output when many are working under very difÏcult circumstances.
The BOA’s response to COVID-19
As part of the move
into the second phase
of the COVID-19
pandemic, the topic
of restarting non-
urgent care is high on
priority lists around
the UK. The BOA
has published its own
guidance to help with
the shift in practice
that will be seen as
we enter this new
stage of response to
COVID-19, and the restarting of elective orthopaedic care. The guidance we have
created includes two documents: one is a summary document, which contains
core principles about restarting aspects of orthopaedic care, whilst the second is a
more detailed guidance document which provides further in depth discussion of
the key points. We are aware that this shift towards restarting care will have many
changes and so we will be updating these documents regularly as more information
becomes available in this evolving situation. The documents can be viewed at:
www.boa.ac.uk/guidance and we welcome any feedback to us at: policy@boa.ac.uk.
Guidance for restarting non-urgent care
Cumberlege Report delayed
The Independent Medicines & Medical Devices
Safety Review was due to publish its report on
surgical mesh implants on 24th March, however
due to the Coronavirus pandemic the Review has
decided to postpone this planned publication.
The BOA will continue to keep abreast of any
developments and will inform members when
the report is published.
MDR regulations
The European Commission has adopted
a proposal to postpone the application
of the Medical Devices Regulation by
one year. This decision has taken into
account the unprecedented challenges
of the coronavirus pandemic and the
need for an increased availability of
vitally important medical devices across
the EU. The BOA will keep members
updated with any further information
we receive. More information and the
full statement can be found at https://
ec.europa.eu/commission/presscorner/
detail/en/ip_20_589.
NICE Joint replacement update
The BOA was expecting the publication
of the NICE Joint replacement (primary):
hip, knee and shoulder guideline in late
March, following a consultation which
we responded to. However, due to the
COVID-19 pandemic, NICE have confirmed
they will not be publishing any draft or final
guidelines until further notice. We will
endeavour to keep members informed with
any updates on this.
BOA Webinar - The Next Phase: Recovery of T&O Surgery
Following the publication of our guidance, the BOA hosted a webinar to address some key
points with regard to restarting of elective and non-urgent care within T&O. The panellists
gave insights into their own experiences, including a presentation on the paediatric
implications from Prof Deborah Eastwood as well as the anaesthetic view from Prof William
Harrop-GrifÏths of the Royal College of Anaesthetists. Following the presentations, time was
given for discussion and questions from the audience, and the BOA would like to thank the
audience for their engaging questions during the second half of the session. We had a large
turnout and very positive response to the webinar and expect this to be the first of many.
In case you missed it you can view the webinar at: https://www.boa.ac.uk/latest-news/
changes-to-orthopaedic-services-during-covid-19.html.
BOA Training Orthopaedic
Trainers (TOTs) and Training
Orthopaedic Education
Supervisors (TOES) courses
Delivery of future BOA-run face-to-face TOTs
and TOES courses is being reviewed in keeping
with the lockdown restriction guidelines. It
is expected that face-to-face delivery of these
courses will resume on the dates listed below.
Further information will be updated on the BOA
website at: https://www.boa.ac.uk/courses
when course bookings are open.
- TOTs: 3rd – 4th September 2020
(BOA London)
- TOTs: 10th – 11th December 2020
(BOA London)
- TOES: 18th December 2020
(BOA London)
JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 07
Latest News
Apply Now: Associate Surgical Specialty Lead (SSL) posts
The BOA is very proud to be supporting NHS
England with their ‘NHS Change Challenge’.
COVID-19 has changed healthcare delivery
in the UK and there are many examples of
new, innovative ways of working that have
been rapidly developed across the NHS.
This initiative aims to capture all of these
beneficial changes across T&O and MSK
services, and lock them into the new ways
of working in the NHS going forward. Two
of our committee members – Nick Aresti
(Orthopaedic Committee) and Alex Trompeter
(Trauma Committee) – have been working as
the Champions for their respective areas on
this project, and we are very excited to see all of
the ideas and responses that are submitted. To
find out more or get involved, visit their website
https://nhschangechallenge.crowdicity.com.
Late in 2019, a new team of SSLs were appointed by the BOA and the Royal College of
Surgeons of England, to help support research in surgery throughout the UK. Since
the launch of this initiative, one of the overriding objectives has been to develop trainee
involvement in surgical clinical research. Three Associate SSL posts have now been created
to give trainees an opportunity to work with the SSLs and shape the course of research in
their speciality. To find out more about these posts, including how to apply, please see the
BOA website: https://www.boa.ac.uk/research/surgical-specialty-leads-for-clinical-trials/
associate-ssl-recruitment.html.
NHS Change Challenge
Virtual Training
Orthopaedic
Trainers (V-TOTs)
With the suspension of face-to-
face educational courses, the BOA
have developed a Virtual Training
Orthopaedic Trainers (V-TOTs) course
facilitated by the BOA Educational
Advisor Lisa Hadfield-Law. The
V-TOTs course is currently being
delivered primarily for those concerned
about meeting imminent CCT
requirements, but anyone who wishes
to register their interest should email
policy@boa.ac.uk to be added to a
waiting list. Details about the structure,
assessment and cost of the V-TOTs
course can be found on our website:
https://www.boa.ac.uk/VTOTS.
UK and Ireland In-Training Examination (UKITE)
The dates for the UKITE 2020 have now been confirmed as 4th – 11th December 2020.
The UKITE is an online annual assessment that allows trainees of all grades to practice
for Part 1 of the FRCS (Tr and Orth) examination, with similar formatted questions based
on the UK and Ireland T&O Curriculum. Information on UKITE is available on the BOA
website: www.boa.ac.uk/ukite.
The BOA is also seeking Editors to contribute to the authoring process of questions for the
UKITE. For more information email ukite@boa.ac.uk.
08 | JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk
Latest News
Trainees are worried about long awaited
rotations, exams, fellowships etc. and face
anxiety at home and at work. Our SAC
continues to work on ways to minimise
the impact of COVID-19 on training and to
reduce worry load. To support this work, the
BOA has produced a screencast suggesting
ways of squeezing the learning juice out
of our unusual and unexpected clinical
experiences. View the screencast at: https://
www.boa.ac.uk/latest-news/trainee-and-tpd-
issues.html.
Many of you will be using this
time to prepare your portfolios to reflect
requirements of the new curriculum. We
have reviewed the GPC framework published
by the GMC which sets out essential Generic
Professional Capabilities (GPCs) integrated
into our new curriculum. We have suggested
specific capabilities which may be relevant to
work during the pandemic and might provide
an opportunity to develop in these areas.
Download the document at: https://www.
boa.ac.uk/resources/generic-professional-
capabilities-gpcs-which-may-be-relevant-to-
work-during-covid-19-pandemic.html.
Those who have been working
alongside others from different specialties or
professions can access invaluable feedback
BOA Educational Support during COVID-19:
A message from Lisa Hadfield-Law, BOA Educational Advisor
• BOAST: Management of patients with urgent orthopaedic conditions and
trauma during the coronavirus pandemic – The BOA Trauma Committee,
alongside several Specialist Societies, worked to produce this BOAST that was
recently updated to include non-urgent paediatric guidance. Download the BOAST
at: https://www.boa.ac.uk/resources/covid-19-boasts-combined.html.
• Information for BOA members on the website – The BOA has compiled
links to a large number of resources across the NHS, PHE, Specialist Societies, the
GMC as well as many other sources. The information covers a wide range of topics
including general professional issues, trainee and TPD issues and infection control
and prevention relevant to T&O. View the various resources at: https://www.boa.
ac.uk/resources/information-for-boa-members-on-trauma-and-orthopaedic-care-in-
the-uk-during-coronavirus-pandemic.html.
• TJTO&C – The JTO editorial team has created the Transient JTO and the
Coronavirus as a place to host discussion and articles during this pandemic.
Read the articles at: www.boa.ac.uk/tjto&c.
• Guidance for casting practice – The BOA Casting Committee created some
guidelines to help with casting practice during the COVID-19 pandemic, due to a
need for reducing hospital attendances and enabling home management where
possible. Download the guidelines at: https://www.boa.ac.uk/resources/guidance-
for-casting-practice-in-the-current-covid-19-pandemic.html.
• Patient FAQs – At the start of the pandemic, we created some patient FAQs
to give some support and reassurance to those patients who may be concerned
with their surgery being cancelled. Access the FAQ’s at: https://www.boa.ac.uk/
resources/coronavirus-boa-faqs-for-patients.html.
discussions. It shouldn’t take long to record
these and we have suggested quick ways to
do this on ISCP at: https://www.boa.ac.uk/
resources/how-to-register-assessors-who-
do-not-have-iscp-accounts.html.
Regional teaching shifted to a virtual
medium remarkably quickly. The BOA has
been able to support regions with ideas to
make sessions work. Amazing progress has
been made by many: terrifically interactive
events even breaking into small groups.
In response to concerns about requirements
for CCT, the BOA evolved their Training
Orthopaedic Trainers into an entirely virtual
programme. They turned this around in seven days
with the first cohort of nine starting on the 24th
April. One participant has already said “Really
getting a lot of useful insight, genuinely wish I’d
done this a lot sooner as a learner.” We are now
turning our attention to virtual preparation for
the new curriculum and the Training Orthopaedic
Educational Supervisors programme. n
Other COVID-19
documents
and resources
available on the
BOA website