01 Dec 2023

JTO - December 2023

Volume 11 Issue 4

From the Executive Editor

As another year comes to an end, it is upsetting to see how many troubled areas there are in our world at present with so much suffering. The recent difficulties in the Middle East are truly saddening and have understandably become front page news – but the Ukrainian crisis continues unabated and the article by our colleagues on Conflict Surgery in the Ukraine (p20-21) highlights how quickly changes can be made when they have to be made, bringing back reflections of the COVID-19 Lockdown changes in healthcare delivery. The article emphasises the need to learn, and to learn quickly, and that all experiences should be used as learning experiences. In Liverpool, it was my privilege to award the 2023 Presidential Merit award to a team: the team who arranged and delivered a series of webinars to help and to educate colleagues in conflict zones. A pertinent reminder that the practice of orthopaedics and trauma is a team sport.

The team is diverse and BOTA and the BOA have made huge strides over recent years to change the face of T&O as shown in the article on p38-41. The authors represent the diverse mix that is our future. The future is definitely bright.

One of the many reasons I enjoying reading the JTO, is its mix of reflection on times past and descriptions of future initiatives and this edition is no different. Tom Quick reminds us of the history of peripheral nerve surgery (p26-30) whilst on p22-24, Joshua Jones and his colleagues invite us to consider turning the ‘phage’ on a new era for the management of bone and joint infection. Chetan Khatri and colleagues continue their theme on delivering innovation and embedding new technologies in surgical practice (p32-34) whilst on p36-37 Richard Deveraux-Phillips asks us to rethink our relationship with bodies involved in not only the regulation of products but also the supply chain that delivers them to our hands.

Our subspecialty section this time goes to the heart of why we are T&O specialists – we like fixing things and making them better but all too often we find ourselves still unable to answer the basic question of ‘why does it hurt, doctor?’ This collection of articles (p46-58) describes some of the advances that have been made in understanding the problem and to structure our commitment to the relief of pain: again teamwork is at the heart of patient care.

It is has been a difficult year in terms of the loss of colleagues who are gone ‘too soon’ and personally, the reflections on lives well lived for two colleagues, one at the RNOH and one from BSCOS (p59), remind me to take at least a small step back, look at life with a clear eye and enjoy the time we have together.

May I take this opportunity to wish you Season’s Greetings with the sincere hope that you will all be able to spend valuable time with friends and family and take the opportunity to remind each other of how important such connections are.

 Deborah Eastwood, Immediate Past President 


Subspecialty Section


Turning a new phage on bone and joint infections

  1. Comeau AM, Hatfull GF, Krisch HM, Lindell D, Mann NH, Prangishvili D. Exploring the prokaryotic virosphere. Research in Microbiology. 2008;159:306-13.
  2. Chanishvili N. Phage Therapy-History from Twort and d’Herelle Through Soviet Experience to Current Approaches. Advances in Virus Research. 2012;83:3-40.
  3. Ferriol-González C, Domingo-Calap P. Phages for Biofilm Removal. Antibiotics. 2020;9:268.
  4. Stacey HJ, De Soir S, Jones JD. The Safety and Efficacy of Phage Therapy: A Systematic Review of Clinical and Safety Trials. Antibiotics. 2022;11:1340.
  5. Uyttebroek S, Chen B, Onsea J, et al. Safety and efficacy of phage therapy in difficult-to-treat infections: a systematic review. Lancet Infect Dis. 2022;22(8):e208-e220.
  6. Genevière J, McCallin S, Huttner A, Pham T-T, Suva D. A systematic review of phage therapy applied to bone and joint infections: an analysis of success rates, treatment modalities and safety. EFORT Open Rev. 2021;6:1148-56.
  7. Clarke A, De Soir S, Jones J. The Safety and Efficacy of Phage Therapy for Bone and Joint Infections: A Systematic Review. Antibiotics. 2020;9:795.
  8. Scottish Health Technologies Group HIS. SHTG Recommendation 2023. Bacteriophage therapy for patients with difficult to treat bacterial infections. Available at: https://shtg.scot/our-advice/bacteriophage-therapy-for-patients-with-difficult-to-treat-bacterial-infections.
  9. Suh GA, Lodise TP, Tamma PD, et al. Considerations for the Use of Phage Therapy in Clinical Practice. Antimicrob Agents Chemother 2022;66(3):e0207121.
  10. Onsea, Soentjens, Djebara, et al. Bacteriophage Application for Difficult-to-treat Musculoskeletal Infections: Development of a Standardized Multidisciplinary Treatment Protocol. Viruses. 2019;11:891.
  11. Doub JB, Wilson E. Observed transaminitis with a unique bacteriophage therapy protocol to treat recalcitrant Staphylococcal biofilm infections. Infection. 2022;50:281-3.
  12. Onallah H, Hazan R, Nir-Paz R, Israeli Phage Therapy Center (IPTC) Study Team. Compassionate Use of Bacteriophages for Failed Persistent Infections During the First 5 Years of the Israeli Phage Therapy Center. Open Forum Infectious Diseases. 2023;10(5):ofad221.
  13. Green SI, Clark JR, Santos HH, et al. A Retrospective, Observational Study of 12 Cases of Expanded-Access Customized Phage Therapy: Production, Characteristics, and Clinical Outcomes. Clinical Infectious Diseases. 2023;77(8):1079-91.
  14. Young MJ, Hall LML, Merabishvilli M, Pirnay J-P, Clark JR, Jones JD. Phage Therapy for Diabetic Foot Infection: A Case Series. Clin Ther. 2023;45(8):797-801.
  15. Jones JD, Stacey HJ, Brailey A, Suleman M, Langley RJ. Managing Patient and Clinician Expectations of Phage Therapy in the United Kingdom. Antibiotics. 2023;12:502.
  16. Clinicaltrials.gov. Clinical trials of phage therapy for bone and joint infections. www.clinicaltrials.gov/search?cond=joint%20infection&term=phage%20therapy&rank=1.
  17. Schooley RT, Biswas B, Gill JJ, et al. Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails To Treat a Patient with a Disseminated Resistant Acinetobacter baumannii Infection. Antimicrobial Agents and Chemotherapy. 2017;61:14.
  18. Aslam S. Bacteriophage therapy as a treatment option for transplant infections. Current Opinion in Infectious Diseases. 2020;33:298-303.

The history of surgery in the treatment of traumatic Brachial Plexus Injuries

  1. Belen D, Aciduman A, Er U. History of peripheral nerve repair: may the procedure have been practiced in Hippocratic School? Surg Neurol. 2009;72(2):190-3; discussion 193-4. 
  2. Lu, J.CY., Chuang, D.CC. (2021). Adult Brachial Plexus Injuries: A Historical Perspective. In: Shin, A.Y., Pulos, N. (eds) Operative Brachial Plexus Surgery. Springer, Cham.
  3. Standring, S. (2020). The History of Nerve Repair. In: Phillips, J., Hercher, D., Hausner, T. (eds) Peripheral Nerve Tissue Engineering and Regeneration. Reference Series in Biomedical Engineering. Springer, Cham.
  4. Wilcox, M., Brown, H., Quick, T. (2020). Clinical Outcome Measures Following Peripheral Nerve Repair. In: Phillips, J., Hercher, D., Hausner, T. (eds) Peripheral Nerve Tissue Engineering and Regeneration. Reference Series in Biomedical Engineering. Springer, Cham.
  5. Quick TJ, Brown H. Evaluation of functional outcomes after brachial plexus injury. Journal of Hand Surgery (European Volume). 2020;45(1):28-33. 
  6. Wilcox M, Rayner MLD, Guillemot-Legris O, Platt I, Brown H, Quick T, Phillips JB. Serum neurofilament light chain measurements following nerve trauma. J Peripher Nerv Syst. 2023;28(3):500-7.

How should we introduce new technologies into surgical practice? Part 2: Collaborative data, the role of randomised trials and emerging approaches

  1. Ben-Shlomo Y, Blom A, Boulton C, Brittain R, Clark E, Dawson-Bowling S, et al. The National Joint Registry 19th Annual Report 2022. 2022.
  2. Wilton T, Skinner JA, Haddad FS. Camouflage uncovered: what should happen next? Bone Joint J. 2023;105-b(3):221-6.
  3. New super registry: all implanted medical devices to be tracked 2023. Available from: www.clinicalservicesjournal.com/story/41811/new-super-registry-all-implanted-medical-devices-to-be-tracked#:~:text=The%20Medical%20Device%20Outcome%20Registry%20will%20be%20responsive%20to%20concerns,and%20improve%20outcomes%20for%20patients.
  4. The UK Confidential Reporting Programme for Aviation and Maritime. Available from: www.chirp.co.uk/information-about.asp.
  5. McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC, et al. No surgical innovation without evaluation: the IDEAL recommendations. Lancet. 2009;374(9695):1105-12.
  6. Craven J, Haddad FS, Perry DC. Introducing new procedures and devices: the IDEAL way. The British Editorial Society of Bone & Joint Surgery London; 2021. p. 1326-7.
  7. Horton R. Surgical research or comic opera: questions, but few answers. Lancet. 1996;347(9007):984-5.
  8. Sayers A, Crowther MJ, Judge A, Whitehouse MR, Blom AW. Determining the sample size required to establish whether a medical device is non-inferior to an external benchmark. BMJ open. 2017;7(8):e015397.
  9. Murray DW, MacLennan GS, Breeman S, Dakin HA, Johnston L, Campbell MK, et al. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of different knee prostheses: the Knee Arthroplasty Trial (KAT). Health technology assessment (Winchester, England). 2014;18(19):1.
  10. Getgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285-97.
  11. Kayani B, Tahmassebi J, Ayuob A, Konan S, Oussedik S, Haddad FS. A prospective randomized controlled trial comparing the systemic inflammatory response in conventional jig-based total knee arthroplasty versus robotic-arm assisted total knee arthroplasty. The Bone & Joint Journal. 2021;103(1):113-22.
  12. Kayani B, Konan S, Huq S, Tahmassebi J, Haddad F. Robotic-arm assisted total knee arthroplasty has a learning curve of seven cases for integration into the surgical workflow but no learning curve effect for accuracy of implant positioning. Knee Surgery, Sports Traumatology, Arthroscopy. 2019;27:1132-41.
  13. Griffin J, Davis ET, Parsons H, Mannion EG, Khatri C, Ellard DR, et al. Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial (RACER-knee): a study protocol. BMJ open. 2023;13(6):e068255.
  14. Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, et al. Considerations and methods for placebo controls in surgical trials (ASPIRE guidelines). Lancet. 2020;395(10226):828-38.
  15. Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-38.
  16. Fernandez MA, Achten J, Parsons N, Griffin XL, Png M-E, Gould J, et al. Cemented or uncemented hemiarthroplasty for intracapsular hip fracture. New England Journal of Medicine. 2022;386(6):521-30.
  17. Metcalfe A, Parsons H, Parsons N, Brown J, Fox J, Mannion EG, et al. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START: REACTS): a group-sequential, double-blind, multicentre randomised controlled trial. Lancet. 2022;399(10339):1954-63.
  18. ROSSINI-2 2023. Available from: www.birmingham.ac.uk/ROSSINI2.
  19. Nuffield Department of Orthopaedics RaMS. REINFORCE  [cited 2023]. Available from: www.ndorms.ox.ac.uk/situ/reinforce.

Culture and diversity within orthopaedics: What have we accomplished and where are we going?

  1. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-92.
  2. General Medical Council (2021). GMC targets elimination of disproportionate complaints and training inequalities. Available at:  www.gmc-uk.org/news/news-archive/gmc-targets-elimination-of-disproportionate-complaints-and-training-inequalities.
  3. General Medical Council (2019). Survey of specialty and associate specialist (SAS) and locally employed (LE) doctors. Available at: www.gmc-uk.org/education/standards-guidance-and-curricula/projects/survey-of-specialty-and-associate-specialist-and-locally-employed-doctors.
  4. The Royal College of Surgeons England (2021). The Royal College – Our Professional Home - An independent review on diversity and inclusion for the Royal College of Surgeons of England - An exciting call for radical change. Availabe at: https://diversity.rcseng.ac.uk/wp-content/uploads/2023/03/RCS-Diversity-report.pdf.
  5. Dwyer S,  Rogan A. Seeing the unseen: Neurodiversity in the emergency department. Emerg Med Australas 2022;34(4):609-12.
  6. Shapiro, DS. The Role of the Scarecrow in Surgery. Am Surg. 2022;88(12):2802-6.
  7. Wallis CJD, Jerath A, Aminoltejari K, Kaneshwaran K, Salles A, Coburn N, et al. Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries. JAMA Surg. 2023;30:e233744.
  8. Begeny CT, Arshad H, Cuming T, Dhariwal DK, Fisher RA, Franklin MD, et al. Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights. Br J Surg. 2023;110(11):1518-26.
  9. The Working Party on Sexual Misconduct in Surgery. WPSMS Report: Breaking the silence. Addressing sexual misconduct in healthcare. September 2023. Available at: www.wpsms.org.uk/docs/Breaking_The_Silence_Addressing_Sexual_Misconduct_In_Healthcare.pdf.
  10. Chou LB, Johnson B, Shapiro LM, Pun S, Cannada LK, Chen AF, et al. Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons. J Am Acad Orthop Surg Glob Res Rev. 2022;6(5):e22.00031.
  11. Cai C, Vandermeer B, Khurana R, Nerenberg K, Featherstone R, Sebastianski M, Davenport MH. The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol. 2020;222(3):224-38.
  12. Hutchings R, Lobont C, Fisher E, Palmer W. Future proof: The impact of parental and caring responsibilities on surgical careers. Nuffield Trust 2023. Available at: www.nuffieldtrust.org.uk/research/future-proof-the-impact-of-parental-and-caring-responsibilities-on-surgical-careers.
  13. British Medical Association (2022). Joint pledge on ending sexism in medicine. Available at: www.bma.org.uk/media/6823/joint-pledge-on-ending-sexism-in-medicine.pdf.
  14. British Orthopaedic Association. Radiation exposure in theatre and associated risks? Available at: www.boa.ac.uk/standards-guidance/radiation-exposure-in-theatre.html.
  15. Royal College of Surgeons England (2023). Parents in Surgery Report. Available at: https://diversity.rcseng.ac.uk/how-we-are-changing/parents-in-surgery.
  16. Franklin M, J Maggs J, Khanduja V. Non-selective state schools engagement programme: The British Hip Society Experience. Journal of Trauma & Orthopaedic Surgery. 2023;11(2):36-8.

Intra-operative breakage of instrumentation during orthopaedic surgery

  1. Haberal B, Beyaz S, Effects of orthopaedic instruments breakage during surgery: A minimum five-year follow-up. Ann Clin Anal Med. 2021;12(4):443-6.
  2. Pichler W, Mazzurana P, Clement H, Grechenig S, Mauschitz R, Grechenig W. Frequency of instrument breakage during orthopaedic procedures and its effects on patients. J Bone Joint Surg Am. 2008;90(12):2652-4.
  3. Price MV, Molloy S, Solan MC, Sutton A, Ricketts DM. The rate of instrument breakage during orthopaedic procedures. Int Orthop. 2002;26(3):185-7.
  4. Dharmshaktu GS, Adhikari N, Mourya P, Bhandari SS, Singh P. Intraoperative instrument breakage during the orthopedic elective procedures: A retrospective single-center experience. J Orthop Spine. 2020;8:80-5.
  5. Hirt U, Auer JA, Perren SM. Drill bit failure without implant involvement — an intraoperative complication in orthopaedic surgery. Injury. 1992;23(Suppl 2):S5-S16.
  6. Jamot S, Razif A, Azhar MM, Abbas AA. Migration of a Broken Drill Bit After Acetabular Fracture Fixation. A Case Report. Malaysian Orthopaedic Journal 2011;5(1):56-9.
  7. Garabadi M, O'Brien S. Broken guidewire retrieval from the hip joint: A case report. Trauma Case Rep. 2021:35:100512.
  8. Fransen P, Bourgeois S, Rommens J.  Kirschner wire migration causing spinal cord injury one year after internal fixation of a clavicle fracture. Acta Orthopædica Belgica. 2007;73:390-2.
  9. Wada S, Noguchi T, Hashimoto T, et al. Successful treatment of a patient with penetrating injury of the esophagus and brachiocephalic artery due to migration of Kirschner wires. Ann Thorac Cardiovasc Surg. 2005;11:313-5.
  10. Hegemann S, Kleining R, Schindler HG, Holthusen H. Kirschner wire migration in the contralateral lung after osteosynthesis of a clavicular fracture. Unfallchirurg. 2005;108:991-3
  11. Nordback I, Markkula H. Migration of Kirschner pin from clavicle into ascending aorta. Acta Chir Scand. 1985;151:177-9.
  12. Lim JW, McMillan TE, Stevenson IM. Broken guidewire intramedullary: what to do now? Ann R Coll Surg Engl. 2021;103(2):e56-e58.

Chronic postsurgical pain: An inevitable consequence of surgery or preventable disease?

  1. Davies HTO, Crombie IK, Macrae WA, Rogers KM. Pain clinic patients in northern Britain. Pain Clin. 1992;5:129-35.
  2. International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021. Available at: https://icd.who.int/browse11.
  3. Fletcher D, Stamer UM, Pogatzki-Zahn E, Zaslansky R, Tanase NV, Perruchoud C, et al. Chronic postsurgical pain in Europe: An observational study. Eur J Anaesthesiol. 2015;32(10):725-34.
  4. Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, et al. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695-702.
  5. Srivastava D, Hill S, Carty S, Rockett M, Bastable R, Knaggs R, et al. Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom. Br J Anaesth. 2021;126(6):1208-16.
  6. Getting It Right First Time. Orthopaedic Elective Surgery - Guide to delivering perioperative ambulatory care for patients with hip and knee pain requiring joint replacement surgery. 2023. Available at: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/07/Ambulatory-Hip-and-Knee-Replacement-Guide-March-2023-FINAL-V1-1.pdf.
  7. Schug SA, Palmer GM, Scott DA, Alcock M, Halliwell R, Mott JF; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020), Acute Pain Management: Scientific Evidence (5th edition), ANZCA & FPM, Melbourne. Available at: www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf.
  8. van Driel MEC, van Dijk JFM, Baart SJ, Meissner W, Huygen FJPM, Rijsdijk M. Development and validation of a multivariable prediction model for early prediction of chronic postsurgical pain in adults: a prospective cohort study. Br J Anaesth. 2022;129(3):407-15.
  9. Nguyen LC, Sing DC, Bozic KJ. Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. J Arthroplasty. 2016;31(9 Suppl):282-7.
  10. Wang L, Chang Y, Kennedy SA, Hong PJ, Chow N, Couban RJ, et al. Perioperative psychotherapy for persistent post-surgical pain and physical impairment: a meta-analysis of randomised trials. Br J Anaesth. 2018;120(6):1304-14.
  11. Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev. 2013;2013(7):CD008307.
  12. Carley ME, Chaparro LE, Choinière M, Kehlet H, Moore A, Van Den Kerkhof E, Gilron I. Pharmacotherapy for the Prevention of Chronic Pain after Surgery in Adults: An Updated Systematic Review and Meta-analysis. Anesthesiology. 2021;135:304-25
  13. Doleman B, Mathiesen O, Sutton AJ, Cooper NJ, Lund JN, Williams JP. Non-opioid analgesics for the prevention of chronic postsurgical pain: a systematic review and network meta-analysis. Br J Anaesth. 2023;130(6):719-28.
  14. Ohnuma T, Raghunathan K, Moore S, Setoguchi S, Ellis AR, Fuller M, et al. Dose-Dependent Association of Gabapentinoids with Pulmonary Complications After Total Hip and Knee Arthroplasties. J Bone Joint Surg Am. 2020;102(3):221-9.
  15. Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, et al. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev. 2018;4(4):CD007105.
  16. Tiippana E, Hamunen K, Heiskanen T, Nieminen T, Kalso E, Kontinen VK. New approach for treatment of prolonged postoperative pain: APS Out-Patient Clinic. Scand J Pain. 2016;12:19-24.