03 Dec 2021

Volume 9 Issue 4

From the Executive Editor

So… where has this year gone? It seems, to me at least, to have flown by. We thought that 2020 was a year like no other but 2021 seems to have been similar but different. There has been much sadness and loss, including one of my mentors (page 62) but now also happier times with parties, weddings, theatre trips and sporting events (and yes I did attend my first ever premier league game!) and simple nights in or out with friends and family.

At work, we continue to tackle a seemingly insuperable mountain of cases that require our skills and care. As we heard presented at the BOA Congress, the stark reality is that with a 5% increase in workload nationally, it would still take us nearly 9-10 years to recover the deficit without counting the potential second wave of lost and late referrals. The pandemic taught us to work differently and showed us that change can be achieved quickly when needs must – well needs must now and as our President says, we must work well with our colleagues, for example at #BestMSK Health, to be innovative and resourceful. At all times we must respect and care for our patients and our trainees – both their viewpoints, one individually (page 22) and one collectively (page 42) have an important place in this edition. In this changing world, the way we deliver education at all levels has undergone a seismic change ( pages 20, 34 & 38) – we may all be ‘webinar-ed’ out but out of this change, good things have happened and they may simply need tweaking as we swing back towards the ‘good old times’. However as 2022 approaches, we must not let ourselves get caught in this wish to ‘go back to how it was’ – the future is bright, the future is different and the future is ours. It is still attracting the brightest and the best trainees and students (page 8).

Along with all this looking forward, there is always scope to be fascinated by our past and if you want to know if you look like Lucy, you should read Kartik Hariharan’s article on the anthropology of the human foot (page 30), and the subspecialty section on the foot and ankle makes interesting reading too.

The new year will bring new members to council with a wide expertise to help us in our work, and by the time you read this, we will have a new Honorary Secretary too! Diversity, equality and inclusivity remain high on our agenda and we are delighted to see this reflected in our Council, Committees and membership. There is still work to be done in terms of gender diversity in the medico-legal world it seems (page 46), and my
personal pledge for 2022 is that we will concentrate on the wider issues of diversity and of engagement.

As with last year, the front cover echoes our sentiments for this year ‘every piece matters’ and on behalf of the BOA and the JTO, I would like to thank all our members from Trainees to AHPs, from students to our SAS and Consultant colleagues for contributing to the bigger picture and making it complete.

We wish you all a relaxing festive season.

Deborah Eastwood, Vice President


Subspecialty Section


Breaking down barriers to flexible training in trauma and orthopaedics

  1. Murphy O. Interview: RCS England’s diversity review - Baroness Helena Kennedy QC and RCS England President Neil Mortensen discuss the independent diversity review and the College's next steps. Bull R Coll Surg Engl. 2021;103:124-9.
  2. Walls J. Flexible Training For A Modern Surgical Workforce. Ann R Coll Surg Engl (Suppl). 2006;88:44-7.
  3. Bellini MI, Graham Y, Hayes C, et al. A woman’s place is in theatre: women’s perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group. BMJ Open. 2019;9:e024349. 
  4. Royal College of Surgeons. Less Than Full Time (LTFT) Training in Surgery: JCST Policy Statement, 2017. Available at: www.rcseng.ac.uk/careers-in-surgery/careers-support/flexible-training-and-working/flexible-training-in-surgery.
  5. NHS Digital. Narrowing of NHS gender divide but men still the majority in senior roles. March 2018. Available at: https://digital.nhs.uk/news/2018/narrowing-of-nhs-gender-divide-but-men-still-the-majority-in-senior-roles. (Accessed 5th November 2021).
  6. NHS Digital. Freedom of information request for the percentage of UK female consultant orthopaedic surgeons. Available at: https://digital.nhs.uk/about-nhs-digital/contact-us/freedom-of-information/freedom-of-information-disclosure-log/september-2021/freedom-of-information-request-nic-581204-c1p2d.  (Accessed 30th December 2021).
  7. Harries RL, Rashid M, Smitham P, et al. What shape do UK trainees want their training to be? Results of a cross-sectional study. BMJ Open. 2016;6:e010461.
  8. Harries RL, Gokani VJ, Smitham P on behalf of the councils of the Association of Surgeons in Training and the British Orthopaedic Trainees Association, et al. Less than full-time training in surgery: a cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce. BMJ Open. 2016;6:e010136.
  9. Hampton, T, Greenhalgh, R, Ryan, D, et al. Female surgical trainee attrition. Bull R Coll Surg Engl. 2016;98:134-7.
  10. Roche CD. Locked in – Locked out: Inflexibility in UK training.  Trauma. 2021;23(2):87-9.
  11. Royal College of Surgeons. Less Than Full Time (LTFT) Training in Surgery: JCST Policy Statement, 2017. Available at: www.rcseng.ac.uk/careers-in-surgery/careers-support/flexible-training-and-working/flexible-training-in-surgery.
Appendix 1 - Thematic Analysis
Appendix 1: Thematic analysis with a sample of the direct quotes from which the themes and subthemes were derived


Why should we care about human factors in surgery?

  1. Panagioti M, Khan K, Keers RN et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019;366:4185.
  2. Parent RJ, Plerhoples TA, Long EE, Zimmer DM, Teshome M, Mohr CJ, Ly DP, Hernandez-Boussard T, Curet MJ, Dutta S. Early, intermediate, and late effects of a surgical skills "boot camp" on an objective structured assessment of technical skills: a randomized controlled study. J Am Coll Surg. 2010;210(6):984-9.
  3. Blackmore C, Austin J, Lopushinsky SR, Donnon T. Effects of postgraduate medical education “boot camps” on clinical skills, knowledge, and confidence:  a meta-analysis. J Grad Med Educ. 2014;6(4):643-52.
  4. Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R. Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg. 2006;244(3):400-9.
  5. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-700.
  6. Whittaker JD, Davison I. A Lack of Communication and Awareness in Nontechnical Skills Training? A Qualitative Analysis of the Perceptions of Trainers and Trainees in Surgical Training. J Surg Educ. 2020;77(4):873-88.
  7. Royal College of Surgeons (2019). Learning from invited reviews. Available at: https://invitedreviews.rcseng.ac.uk/
  8. Heyhoe J, Birks Y, Harrison R, O’Hara J, Cracknell A, Lawton R. The role of emotion in patient safety : Are we brave enough to scratch beneath the surface? J R Soc Med. 2016;109(2):52-8.

Collaborative ankle arthritis networks

  1. Glazebrook M, Daniels T, Younger A, Foote CJ, Penner M, Wing K, Lau J, Leighton R, Dunbar M. Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis. J Bone Joint Surg Am. 2008 Mar;90(3):499-505. doi: 10.2106/JBJS.F.01299.
  2. Board NE, editor. National joint registry 16th annual report. National Joint Registry; 2019 p. 163.
  3. S. Bendall, P. Halliwell, A. Goldberg et al., Ankle Arthritis Networking: Getting the right treatment to the right patient first time, Foot Ankle Surg 2021: 1268-7731
  4. Gøthesen O, Espehaug B, Havelin L, et al. Survival rates and causes of revision in cemented primary total knee replacement: a report from the Norwegian arthroplasty register 1994-2009. Bone Joint J. 2013;95-B(5):636–642.
  5. Badawy M, Espehaug B, Indrekvam K, Furnes O. Impact of procedure volume on the results of total knee arthroplasty. J Bone Joint Surg Br. 2012;94-B (SuppXXXVII):141.
  6. Katz JN, Losina E, Barrett J, et al. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2001;83-A(11):1622–1629.
  7. Katz JN, Barrett J, Mahomed NN, et al. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004;86-A(9):1909–1916.
  8. Bloch B, Mends L, James P, Manktelow A. Two-year experience of a ‘hub and spoke’ revision arthroplasty network: 1000 cases and counting. Bone Joint J.2018;100-B( Supp 11):18.

The history of conservative management of acute Achilles tendon ruptures – “the other Northern Irish protocol”

  1. Wallace RGH, Heyes GJ, Michael ALR. The non-operative functional management of patients with a rupture of the tendo achilles leads to low rates of re-rupture. J Bone Joint Surg Br. 2011 Oct;93(10):1362-6.
  2. Hutchison AM, Topliss C, Beard D, Evans RM, Williams P. The treatment of a rupture of the Achilles tendon using a dedicated management programme. Bone Joint J. 2015 97(4), pp.510-515.
  3. Maempel JF, Clement ND, Wickramasignghe NR, Duckworth AD, Keating JF. Operative repair of acute achilles tendon rupture does not give superior patient-reported outcomes to nonoperative management . Bone Joint J. 2020 Jul;102-B(7):933-940.
  4. Lawrence GH , Cave EF, O'Conner H. Injury to the Achilles tendon Experience at the Massachusetts General Hospital, 1900-1954. Am J Surg. 1955 89: 795-802.
  5. Yassin M, Myatt R, Thomas W, Gupta V, Hoque T, Mahadevan D. Does size of tendon gap affect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation?. Bone Joint J. 2020 Nov;102-B(11):1535-1541.
  6. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406-14.
  7. Costa ML, Achten J, Marian IR, Dutton SJ, Lamb SE, Ollivere B, Maredza M, Petrou S, Kearney RS. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation. UKSTAR trial collaborators. Lancet. 2020 Feb 8;395(10222):441-448.