04 Jun 2021

Volume 9 Issue 2

From the Executive Editor

The image on the front cover represents a stark view of what 2020 meant for us and for our patients. We were essentially closed for business. The figures in terms of lost opportunities to fix people and lost opportunities to train our colleagues are huge and there has been a significant impact on the quality of life of those we care for, those we support and ourselves. The full cost has yet to be counted.

Our ‘Restart’ and ‘Recovery’ plans seem to involve asking teams to work harder and longer – not necessarily recognised strategies for efficient and effective healthcare delivery with a tired workforce. Certainly there is some evidence to support the use of hot/cold sites and the BOAST Providing a Continuous Safe Elective Orthopaedic Environment may help us protect a resourced bed base in the future and to utilise it well. The article from the NJR (page 38) highlights figures from 2020 showing both a sharp drop and significant variation in elective activity. Northern Ireland and Wales were particularly badly affected and significant variation is seen across England with, for example, one region managing only 33% of their ‘usual’ TKR activity. Some of the variation may be explained by the availability of hot/cold sites. The overall reduction, whichever way you look at it, is immense and recovery will not be instantaneous – the politicians and the public must not be fooled by the offer of a ‘quick fix’; there is none.

Now is the time for innovative thinking and to ensure that we challenge for change to improve MSK health for all. We are being asked to define areas for improvement rapidly without, I fear, the realisation that it takes time to develop a good and workable idea. We must ensure that change is not enacted just for change’s sake.

If we want to think about change, then the articles on sham/placebo surgery (page 54) are entertaining and informative in equal measure and certainly do challenge the way we think about our surgical equipoise and how we deliver surgical research. We do have to question.

All those of us who train are also going to have to get to grips with the new curriculum (page 26) – please do not leave it too late to learn about the MCRs, CiPs and the GPS – as our President says in his editorial, acronyms are on the up and we must be up with them.

The contribution from the medico-legal team (page 50) regarding the management of our patients who are Jehovah’s Witnesses may make you consider ideas that you have previously taken for granted and reminds us that informed consent is a two way process - the surgeon must be informed, and this article does inform.

Another contribution that perhaps challenges our practice is the article on the use of tourniquets in total knee replacement surgery (page 42). Our trauma colleagues might feel that this is just the tip of the iceberg in asking us to challenge our views on tourniquet use more generally. Why not join the debate and submit your views to the Transient Journal?

Thank you to the 1,300 people who responded to our Burnout Survey in January – the wellbeing of you and your team is important, so please take care and be kind to yourself and those around you (page 20).

Deborah Eastwood, Vice President Elect


Subspecialty Section


BOA Burnout and Wellbeing Survey Infographic and Results: time for a culture change?

  1. Schaufeli WB, Greenglass ER. Introduction to special issue on burnout and health. Psychol Health. 2001;16(5):501-10.
  2. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-13.
  3. Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Burnout and perceived quality of care among German clinicians in surgery. Int J Qual Health Care. 2010;22(6):525-30.
  4. Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC, et al. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111(2):170-5.
  5. Caesar B. Double pandemic, Dr Forte and the fork in our road. Journal of Trauma and Orthopaedics. 2020;8(4):31-3.
  6. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
  7. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-300.
  8. Firth-Cozens J, Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44(7):1017-22.
  9. Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-71.
  10. Sharma A, Sharp DM, Walker LG, Monson JR. Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service. Psychooncology. 2008;17(6):570-6.
  11. Siu C, Yuen SK, Cheung A. Burnout among public doctors in Hong Kong: cross-sectional survey. Hong Kong Med J. 2012;18(3):186-92.
  12. Shanafelt TD, Raymond M, Kosty M, Satele D, Horn L, Pippen J, et al. Satisfaction with work-life balance and the career and retirement plans of US oncologists. J Clin Oncol. 2014;32(11):1127-35.
  13. Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res. 2014;14:254.
  14. Shanafelt T, Sloan J, Satele D, Balch C. Why do surgeons consider leaving practice? J Am Coll Surg. 2011;212(3):421-2.
  15. Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev. 2015;36:28-41.
  16. Asai M, Morita T, Akechi T, Sugawara Y, Fujimori M, Akizuki N, et al. Burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients: a cross-sectional nationwide survey in Japan. Psychooncology. 2007;16(5):421-8.
  17. Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-74.
  18. Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.
  19. van der Heijden F, Dillingh G, Bakker A, Prins J. Suicidal thoughts among medical residents with burnout. Arch Suicide Res. 2008;12(4):344-6.
  20. Oussedik S, MacIntyre S, Gray J, McMeekin P, Clement ND, Deehan DJ. Elective orthopaedic cancellations due to the COVID-19 pandemic: where are we now, and where are we heading? Bone Jt Open. 2021;2(2):103-10.
  21. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ. 2020;368:m1211.
  22. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
  23. Bolderston H, Greville-Harris M, Thomas K, Kane A, Turner K. Resilience and surgeons: train the individual or change the system? The Bulletin of the Royal College of Surgeons of England. 2020;102(6):244-7.
  24. Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs. 2005;51(3):276-87.
  25. Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med. 2019;170(11):784-90.
  26. Kristensen TS, Hannerz H, Hogh A, Borg V. The Copenhagen Psychosocial Questionnaire--a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health. 2005;31(6):438-49.
  27. Office of National Statistics. Ethnic group, national identity and religion. Available from: www.ons.gov.uk/methodology/classificationsandstandards/measuringequality/ethnicgroupnationalidentityandreligion.
  28. Office of National Statistics. Guidance for questions on sex, gender identity and sexual orientation for the 2019 Census. Rehearsal for the 2021 Census. Available from: www.ons.gov.uk/census/censustransformationprogramme/questiondevelopment/genderidentity/guidanceforquestionsonsexgenderidentityandsexualorientationforthe2019censusrehearsalforthe2021census.
  29. Caesar B, Barakat A, Bernard C, Butler D. Evaluation of physician burnout at a major trauma centre using the Copenhagen burnout inventory: cross-sectional observational study. Ir J Med Sci. 2020;189(4):1451-6.
  30. Ng APP, Chin WY, Wan EYF, Chen J, Lau CS. Prevalence and severity of burnout in Hong Kong doctors up to 20 years post-graduation: a cross-sectional study. BMJ Open. 2020;10(10):e040178.
  31. Messias E, Gathright MM, Freeman ES, Flynn V, Atkinson T, Thrush CR, et al. Differences in burnout prevalence between clinical professionals and biomedical scientists in an academic medical centre: a cross-sectional survey. BMJ Open. 2019;9(2):e023506.
  32. Balch Samora J, Van Heest A, Weber K, Ross W, Huff T, Carter C. Harassment, Discrimination, and Bullying in Orthopaedics: A Work Environment and Culture Survey. J Am Acad Orthop Surg. 2020;28(24):e1097-e104.
  33. Lin JS, Lattanza LL, Weber KL, Balch Samora J. Improving Sexual, Racial, and Ethnic Diversity in Orthopedics: An Imperative. Orthopedics. 2020;43(3):e134-e40.
  34. Sprow HN, Hansen NF, Loeb HE, Wight CL, Patterson RH, Vervoort D, et al. Gender-Based Microaggressions in Surgery: A Scoping Review of the Global Literature. World J Surg. 2021;45(5):1409-22.
  35. Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. JAMA Surg. 2019;154(9):868-72.
  36. British Orthopaedic Association. About Us. Available from: www.boa.ac.uk/about-us.html.

Tourniquet use in knee replacement – the why, the what and how to do without

  1. Gibbs V, Price A, Wall P, Peter D. Surgical tourniquet use in total knee repalcement surgery: a survey of BASK members. The Knee. 2016;23:3-4.
  2. Arthur J, Spangehl M. Tourniquet use in total knee arthroplasty. J Knee Surg. 2019;32:719-29.
  3. Bucher T, Butler M, Lee C, Eyres K, Mandalia V, Toms A. TKR without tourniquet: a laboratory study investigating the quality of the tibial cement mantle when using metaphyseal suction and cement gun. Journal of Arthroscopy and Joint Surgery. 2015;2:62-6.
  4. Palmer SH, Graham G. Tourniquet-induced rhabdomyolysis after total knee replacement. Ann R Coll Surg Engl. 1994;76(6):416-7.
  5. Townsend HS, Goodman SB, Schurman DJ, Hackel A, Brock-Utne JG. Tourniquet release: systemic and metabolic effects. Acta Anaesthesiol Scand. 1996;40(10):1234-7.
  6. Ahmed I, Chawla A, Underwood M, Price A, Metcalfe A, Hutchinson C, et al. Tourniquet use for knee replacement surgery. Cochrane Database of Systematic Reviews. 2020;12:CD012874
  7. Yasin S, Sood C, Dubey R, Manzoor N, Kompani A. Blood loss in tourniquet in total knee replacement surgery: a randomised control study. Journal of Arthroscopy and Joint Surgery. 2020;7(3):122-6.
  8. Cai DF, Fan QH, Zhong HH, Peng S, Song H. The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: a meta-analysis. J Orthop Surg Res. 2019;14(1):348.

Returning to trauma and orthopaedic training with SuppoRTT

  1. Nash E, Curry JI, Blackburn SC. Return to the theatre after an interval. The Bulletin of the Royal College of Surgeons of England. 2018;100(6):277-81.
  2. Williams S, Bowbrick VA, Chan S. Return to work for higher surgical trainees: a deanery perspective. The Bulletin of the Royal College of Surgeons of England 2020;102(6):264-9. 
  3. Academy of Medical Royal Colleges (2017). Return to Practice Guidance. Revision. Available from: www.aomrc.org.uk/reports-guidance/revalidation-reports-and-guidance/return-practice-guidance-2017-revision.
  4. Royal College of Anaesthetists (2015). Returning to work after a period of absence. Available from: www.rcoa.ac.uk/sites/default/files/documents/2019-09/ReturnToWork2015.pdf
  5. Royal College of Obstetricians and Gynaecologists (2014). Becoming Tomorrow’s Specialist. Available from: www.rcog.org.uk/globalassets/documents/guidelines/becoming-tomorrows-specialist.pdf.
  6. Paediatric Return to Acute Clinical Practice (PRACP) Course. Available at: https://londonpaediatrics.co.uk/current-trainees/returning-to-clinical-practice.

Current medico-legal considerations in the orthopaedic treatment of Jehovah’s Witnesses

  1. Schloendorff v Society of New York Hospital [1914] 105 NE 92 (N.Y. 1914).
  2. The Human Rights Act 1998, Chapter 42. London: Stationery Office.
  3. Re T (Adult: Refusal of Treatment) [1993] Fam 95, at 115
  4. General Medical Council (2020). Personal beliefs and medical practice (updated November 2020). Available at: www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice
  5. Royal College of Surgeons of England (2016). Caring for patients who refuse blood. Available at: www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/caring-for-patients-who-refuse-blood.
  6. Children’s Act 1989, Chapter 41, Section 8, Specific Issue Orders. Available at: www.legislation.gov.uk/ukpga/1989/41/contents/enacted.
  7. Royal College of Surgeons of England (2016). Caring for patients who refuse blood. Available at: www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/caring-for-patients-who-refuse-blood.
  8. Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee. Patient Blood Management. Available at: www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management.
  9. Clevenger B, Mallett SV, Klein AA, Richards T. Patient blood management to reduce surgical risk. 

    Br J Surg. 2015;102(11):1325-37; discussion 1324.

  10. Klein AA, Bailey CR, Charlton A, Lawson C, Nimmo AF, Payne S, et al. Association of Anaesthetists: anaesthesia and peri-operative care for Jehovah’s Witnesses and patients who refuse blood. Anaesthesia. 2019;74(1):74-82.

Are surgical placebo controls ethically justifiable?

  1. Campbell MK, Skea ZC, Sutherland AG, Cuthbertson BH, Entwistle VA, McDonald AM, et al. Effectiveness and cost-effectiveness of arthroscopic lavage in the treatment of osteoarthritis of the knee: a mixed methods study of the feasibility of conducting a surgical placebo-controlled trial (the KORAL study). Health Technol Assess. 2010;14(5):1-180.
  2. Lubowitz JH, Provencher MT, Rossi MJ. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Part 2. Arthroscopy. 2014;30(6):654-5.
  3. Wartolowska K, Judge A, Hopewell S, Collins GS, Dean BJF, Rombach I, et al. Use of placebo controls in the evaluation of surgery: systematic review. BMJ. 2014;348:g3253.
  4. 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.
  5. Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-8.
  6. Nishimura A, Carey J, Erwin PJ, Tilburt JC, Murad MH, McCormick JB. Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials. BMC Med Ethics. 2013;14:28.
  7. Weijer C, Shapiro SH, Cranley Glass K. For and against: clinical equipoise and not the uncertainty principle is the moral underpinning of the randomised controlled trial. BMJ. 2000;321(7263):756-8.
  8. Hey SP, Weijer C. What questions can a placebo answer? Monash Bioeth Rev. 2016;34(1):23-36.

Getting placebo controls of surgery to work (in orthopaedics) – the CSAW experience

  1. Beard D, Rees J, Rombach I, Cooper C, Cook J, Merritt N, et al. The CSAW Study (Can Shoulder Arthroscopy Work?) - a placebo-controlled surgical intervention trial assessing the clinical and cost effectiveness of arthroscopic subacromial decompression for shoulder pain: study protocol for a randomised controlled trial. Trials. 2015;16:210.
  2. Donovan JL, Rooshenas L, Jepson M, Elliott D, Wade J, Avery K, et al. Optimising recruitment and informed consent in randomised controlled trials: the development and implementation of the Quintet Recruitment Intervention (QRI). Trials. 2016;17(1):283.
  3. Donovan JL, Paramasivan S, de Salis I, Toerien M. Clear obstacles and hidden challenges: understanding recruiter perspectives in six pragmatic randomised controlled trials. Trials. 2014;15:5.
  4. Jepson M, Elliott D, Conefrey C, Wade J, Rooshenas L, Wilson C, et al. An observational study showed that explaining randomization using gambling-related metaphors and computer-agency descriptions impeded randomized clinical trial recruitment. J Clin Epidemiol. 2018;99:75-83.
  5. Mills N, Donovan JL, Wade J, Hamdy FC, Neal DE, Lane JA. Exploring treatment preferences facilitated recruitment to randomized controlled trials. J Clin Epidemiol. 2011;64(10):1127-36.
  6. Rooshenas L, Elliott D, Wade J, Jepson M, Paramasivan S, Strong S, et al. Conveying Equipoise during Recruitment for Clinical Trials: Qualitative Synthesis of Clinicians' Practices across Six Randomised Controlled Trials. PLoS Med. 2016;13(10):e1002147.
  7. 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.

The last word on placebo-controlled surgical trials

  1. Kuhse H, Singer P. A Companion to Bioethics. John Wiley & Sons; 2013.
  2. Altman DG, Bland JM. Absence of evidence is not evidence of absence. BMJ (Clinical Research Ed). 1995;311:485.
  3. Harris I. Surgery, the ultimate placebo: A surgeon cuts through the evidence. NewSouth; 2016.
  4. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015;373:1597-606.
  5. Sochacki KR, Mather RC, Nwachukwu BU, Dong D, Nho SJ, Cote MP, et al. Sham Surgery Studies in Orthopaedic Surgery May Just Be a Sham: A Systematic Review of Randomized Placebo-Controlled Trials. Arthroscopy. 2020;36:2750-2762.e2. 
  6. 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;395:828-38. 
  7. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. N Engl J Med. 2002;347:81-8.
  8. Jacquet C, Pujol N, Pauly V, Beaufils P, Ollivier M. Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017. Orthop Traumatol Surg Res. 2019;105(4):677-682.
  9. Parker BR, Hurwitz S, Spang J, Creighton R, Kamath G. Surgical Trends in the Treatment of Meniscal Tears: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database. Am J Sports Med. 2016;44:1717-23.
  10. Ardern CL, Paatela T, Mattila V, Taimela S, Järvinen TLN. When taking a step back is a veritable leap forward. Reversing decades of arthroscopy for managing joint pain: Five reasons that could explain declining rates of common arthroscopic surgeries. British Journal of Sports Medicine. 2020;54:1312-3. 
  11. Abram SGF, Beard DJ, Price AJ. Arthroscopic meniscal surgery: A national society treatment guideline and consensus statement. Bone Joint J. 2019;101-B:652-9. 
  12. Beaufils P, Becker R, Kopf S, Englund M, Verdonk R, Ollivier M, et al. Surgical Management of Degenerative Meniscus Lesions: The 2016 ESSKA Meniscus Consensus. Knee Surg Sports Traumatol Arthrosc. 2017;25:335-46.