10 Jun 2022

Volume 10 Issue 2

From the Executive Editor

Flaming June has arrived, or hopefully it will have by the time you read this, although it’s currently pouring down on the south coast as I write this editorial.

This is my first one having taken over from Deborah Eastwood and I hope I can do justice to her and all she has done during her time as Executive Editor.

In her last editorial back in March, she reflected on the uncertainty of the world we found ourselves in but also the hope for a reduction in COVID numbers and the potential for a sort of normality in the months to come.

Well, COVID is beginning to settle but that was not before Omicron reminded us how quickly things can change. As we look to recover from a pandemic what a World, we now live in. A war in Europe for the first time in nearly 80 years and inflation going through the roof on the home front. To cap it all, as COVID recedes, at least for the time being, we have a waiting list mountain to climb making Mike Reed’s article on BODS (page 24) all the more important in the current climate.

However, there is much change for good in our profession although a long way to go.

In this edition of the JTO we continue with the theme of Equality and Diversity with thought provoking articles on disability, socioeconomic profiles in the BOA (page 32) and the barriers to flexible training in the UK (page 28) which despite significant advances in recent years still exists and no doubt adversely affect some people’s decision to consider T&O as a realistic career option. Finally, the trainee article from BOTA considers ‘Professionalism in T&O’ (page 40).

Alisdair Felstead considers the need for a change in surgical mindset in reviewing Matthew Syed’s well known book ‘Black Box thinking’ (page 20). Ian Winson was calling for a ‘Just Culture’ many years ago but sadly we seem unable to move on from the blame game!

Professor Eastwood makes a rapid return for a guest appearance as editor of our subspecialty section considering the ‘Ability in disability’ (page 46) reflecting in part, on some astonishing achievements of those considered ‘disabled’. Virginie Pollet’s article (page 48) highlights why a disability is not a ‘non-ability’ and shouldn’t limit children with an impairment from participating in sport. John McFall (page 52) gives his own personal account as an amputee of the opportunities, both sporting and professional, he took up and Louise McMenemy’s article (page 56) highlights how advances in orthotic design are benefiting young patients returning to impact activities.

Finally, our sister publication ‘The Transient Journal’ is undergoing a change. Introduced in the height of the pandemic by Bob Handley to facilitate rapid dissemination of information and best practice, it has been a huge success. However it must evolve and continue as the online arm of the BOA, and so under the editorship of Caroline Hing the Transient Journal is to become permanent and will be rebranded as ‘Orthopaedics Online’. I hope you will continue to support it.

I do hope you will enjoy this edition of the JTO and hopefully we see some sunshine in the months to come.

 Simon Hodkinson, Vice President Elect


Subspecialty Section

References and Appendices

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


How Diverse and Inclusive are the Demographic, Socio-economic and Disability Profiles of the British Orthopaedic Association membership in the United Kingdom?

  1. Hunt V, Layton D, Prince S. Diversity Matters. McKinsey & Company (2015). Available at: www.mckinsey.com/~/media/mckinsey/business%20functions/organization/our%20insights/why%20diversity%20matters/diversity%20matters.ashx.
  2. Dahlerup D. From a Small to a Large Minority: Women in Scandinavian Politics. Scandinavian Political Studies. 1988;11(4):275-98.
  3. Day M, Owens J, Caldwell L. Breaking Barriers: A Brief Overview of Diversity in Orthopedic Surgery. Iowa Orthop J. 2019;39(1):1-5.
  4. Day C, Lage D, Ahn C. Diversity based on race, ethnicity, and sex between academic orthopaedic surgery and other specialties: a comparative study. J Bone Joint Surg Am. 2010;92(13):2328-35.
  5. Association of American Medical Colleges (2015). Physician Specialty Data Report - Active physicians by sex and specialty. Available at: www.aamc.org/data-reports/workforce/interactive-data/active-physicians-sex-and-specialty-2015.
  6. NHS Digital (2019). Medical and Dental staff by gender specialty and grade AH2667. Available at: https://digital.nhs.uk/data-and-information/find-data-and-publications/supplementary-information/2019-supplementary-information-files/medical-and-dental-staff-by-gender-specialty-and-grade-ah2667.
  7. NHS Digital. Trauma and Orthopaedics Surgery staff in post data 2021. Available at: https://digital.nhs.uk/supplementary-information/2021/trauma-and-orthopaedics-surgery-staff-in-post-data-pack-may-21. [Accessed 10th April 2022]
  8. Poon S, Kiridly D, Mutawakkil M, Wendolowski S, Gecelter R, Kline M, et al. Current Trends in Sex, Race, and Ethnic Diversity in Orthopaedic Surgery Residency. J Am Acad Orthop Surg. 2019;27(16):e725-e733.
  9. Green J, Chye V, Hiemstra L, Fellander-Tsai L. Diversity: Women in orthopaedic surgery -a perspective from the International Orthopaedic Diversity Alliance. Journal of Orthopaedics and Trauma. 2020;8(1):44-51.
  10. Acuña A, Sato E, Jella T, Samuel L, Jeong S, Chen A, et al. How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry. Clin Orthop Relat Res. 2021;479(12):2757-8.
  11. British Orthopaedic Association. Diversity and Inclusion Strategy 2020. Available at: www.boa.ac.uk/static/372e8ce9-004a-48d9-981b08cca1ac6797/DI-Strategy.pdf.
  12. Wilson M, May D, Kelly J. Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethn Dis. 1994;4(1):57-67.
  13. Dunlop D, Manheim L, Song J, Sohn M, Feinglass J, Chang H, et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46(2):200-8
  14. Dunlop D, Song J, Manheim L, Chang R. Racial disparities in joint replacement use among older adults. Med Care. 2003;41(2):288-98.
  15. Markes A, Pareek A, Mesfin A, Benjamin MC, Ward D. Racial and Gender Shoulder Arthroplasty Utilization Disparities of High- and Low-Volume Centers in New York State. J Shoulder Elb Arthroplast. 2021;5:24715492211041901.
  16. Nwachukwu B, Kenny A, Losina E, Chibnik L, Katz J. Complications for racial and ethnic minority groups after total hip and knee replacement: a review of the literature. J Bone Joint Surg Am. 2010;92(2):338-45.
  17. Lavernia C. Race and outcomes in Total Hip Arthroplasty. Orthopaedic Proceedings. 2021;103-B:SUPP_14.
  18. Dy C, Lane J, Pan T, Parks M, Lyman S. Racial and Socioeconomic Disparities in Hip Fracture Care. J Bone Joint Surg Am. 2016;98(10):858-65.
  19. Todd K, Samaroo N, Hoffman J. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537-9.
  20. Epps C, Ware L, Packard A. Ethnic wait time differences in analgesic administration in the emergency department. Pain Manag Nurs. 2008;9(1):26-32.
  21. Paul R, Lee D, Brutico J, Tjoumakaris F, Ciccotti M, Freedman K. Reporting and Analyzing Race and Ethnicity in Orthopaedic Clinical Trials: A Systematic Review. J Am Acad Orthop Surg Glob Res Rev. 2021;5(5):e21.00027.
  22. Lee C. "Race" and "ethnicity" in biomedical research: how do scientists construct and explain differences in health? Soc Sci Med. 2009;68(6):1183-90.
  23. Mathur R, Grundy E, Smeeth L. NCRM Working Paper Series: Availability and use of UK based ethnicity data for health research. National Centre for Research Methods 2013. Available at: https://eprints.ncrm.ac.uk/id/eprint/3040/1/Mathur-_Availability_and_use_of_UK_based_ethnicity_data_for_health_res_1.pdf.
  24. Royal Australasian College of Surgeons (2020). Survey report. Breaking barriers; developing drivers for female surgeons. Available at: www.surgeons.org/-/media/Project/RACS/surgeons-org/files/operating-with-respectcomplaints/Break-barriers-report_2020.pdf?rev=6d32e206ee4b4d12aa916ec5cb8886d0&hash=5113131E0530FBEDBBD6FACE5B970CD0.
  25. Rao R, Khatib O, Agarwal A. Factors Motivating Medical Students in Selecting a Career Specialty: Relevance for a Robust Orthopaedic Pipeline. J Am Acad Orthop Surg. 2017;25(7):527-35.

The use of Orthoses to return young patients to impact activities following complex foot and ankle injuries

  1. Hansen ST. The type-IIIC tibial fracture. Salvage or amputation. J Bone Joint Surg Am. 1987;69(6):799-800.
  2. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma. 2000;14(7):455-66.
  3. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: Development and Final Revision of a Health Status Measure. Med Care. 1981;19(8):787-805.
  4. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, et al. Long-term persistence of disability following severe lower-limb trauma: Results of a seven-year follow-up. J Bone Joint Surg Am. 2005;87(8):1801-9.
  5. Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am. 2013;95(2):138-45.
  6. Boos CJ, Schofield S, Cullinan P, Dyball D, Fear NT, Bull AMJ, et al. Association between combat-related traumatic injury and cardiovascular risk. Heart. 2022;108(5):367-74.
  7. Ounpuu S, Bell KJ, Davis RB, DeLuca PA, Õunpuu S, Bell KJ, et al. An evaluation of the posterior leaf spring orthosis using joint kinematics and kinetics. J Pediatr Orthop. 1996;16(3):378-84.
  8. Owens JG, Blair JA, Patzkowski JC, Blanck RV, Hsu JR. Return to Running and Sports Participation After Limb Salvage. J Trauma Inj Infect Crit Care. 2011;71(supplement):S120-4.
  9. Patzkowski JC, Owens JG, Blanck R V., Kirk KL, Hsu JR. Management of Posttraumatic Osteoarthritis With an Integrated Orthotic and Rehabilitation Initiative. J Am Acad Orthop Surg. 2012;20:S48-53.
  10. Bedigrew KM, Patzkowski JC, Wilken JM, Owens JG, Blanck RV, Stinner DJ, et al. Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma? Clin Orthop Relat Res. 2014;472(10):3017-25.
  11. Sheean AJ, Tennent DJ, Owens JG, Wilken JM, Hsu JR, Stinner DJ. Effect of Custom Orthosis and Rehabilitation Program on Outcomes Following Ankle and Subtalar Fusions. Foot Ankle Int. 2016;37(11):1205-10.
  12. Potter BK, Sheu RG, Stinner D, Fergason J, Hsu JR, Kuhn K, et al. Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma. J Bone Jt Surg. 2018;100(20):1781-9.
  13. Crowell MS, Deyle GD, Owens J, Gill NW. Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series. J Man Manip Ther. 2016;24(1):34-44.
  14. Wilken JM, Darter BJ, Goffar SL, Ellwein JC, Snell RM, Tomalis EA, et al. Physical Performance Assessment in Military Service Members. J Am Acad Orthop Surg. 2012;20:S42-7.
  15. Ladlow P, Bennett N, Phillip R, Dharm-Datta S, McMenemy L, Bennett AN. Passive-dynamic ankle-foot orthosis improves medium-term clinical outcomes after severe lower extremity trauma. J R Army Med Corps. 2019;165(5):330-7.
  16. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project (LEAP) - The Best Available Evidence on Limb-Threatening Lower Extremity Trauma. Orthop Clin North Am. 2010;41(2):233-9.
  17. Hill O, Bulathsinhala L, Eskridge SL, Quinn K, Stinner DJ. Descriptive Characteristics and Amputation Rates With Use of Intrepid Dynamic Exoskeleton Orthosis. Mil Med. 2016;181(S4):77-80.