06 Jun 2023

JTO - June 2023

Volume 11 Issue 2

From the Executive Editor

A warm welcome to the June edition of the JTO.  A year ago, when I welcomed you to the June edition of 2022 in the pouring rain on the south coast, I contemplated the possibility of flaming June arriving.  It did indeed arrive and continued unabated into July and August.

Sadly, many of last year’s issues remain, and we now have our nursing and junior doctor colleagues involved in a series of strikes, the like of which we have never seen before.  However, we soldier on and in this edition, we start with congratulations to all our runners, cyclists, and last but by no means least, our home-grown Tough Mudder team, raising money for Joint Action.  Many congratulations and thanks to all who took part.  Judging by the photographs, I’m glad the BOA is not responsible for their laundry bill!

We move on to a reflective piece on the origins of the NHS by our own Head of Policy and Public Affairs, Gary Robjent, as we celebrate its 75th anniversary.  As he mentions, so much of what we have today has its origins in the two worlds wars and their aftermath, and to the traumatic fallout of the industrialisation of the UK.

The first of a series of articles from the NJR, as it celebrates its 20th anniversary, reflects on the positive changes in the outcomes from joint replacement, noting the continuing fall in the mortality of the operation, to the fact that 90% of hip and knee replacements now last more than 15 years.

Following on the theme of joint replacement, Andrew Hamer et al records the development and roll out of the revision hip networks.  I am sure that this will not be the last national networks we see develop in our speciality, all to the benefit of our patients.

Andrew Manktelow has produced a timely article on the activities in the independent sector, and raises the potential disconnect between practitioners in the independent sector and the BOA.  As an addendum to this article, I would invite anybody who wishes to engage with the BOA on this or any other issue that needs our attention to use the JTO e-mail address ([email protected]).

Fergal Monsell discusses the evolution of the BOAST guidelines, highlighting that in the future BOAST guidelines will continue, but on subjects of a generic interest to all orthopaedic surgeons and these will now be supplemented by SpecS documents focusing on specific issues related to specialties.

The next two articles focus on health and safety at work.  The article by Hannah Sevenoaks and her colleagues discusses the issue of improving the protection of the breast in female orthopaedic surgeons, raising issues of potentially inadequate protection from the conventional tabard-type lead gowns.  The next article by Hiro Tanaka – the first in a series of health and safety articles to be produced – discusses in more detail the generic issues of radiation and how we should pay attention to protecting ourselves. Something that I suspect we have all at some stage in our careers ignored.

This month’s trainee section looks at the British Hip Society’s programme that they ran during their annual meeting, engaging non-selective state schools with the idea of a career in medicine, and subsequently trauma and orthopaedic surgery.  We are indebted to Marietta Franklin and her colleagues in the British Hip Society for producing not only the article, but for creating the project as an example of engaging our profession with a wider audience.

Simon Britten, as chair of the medical legal committee at the BOA, has produced an interesting article on the issue of clinical guidelines and standards of care, and delves into their place in ours and our legal colleague’s practice.

Finally, but by no means least, we come on to our specialty features for the June edition, edited by Anna Clarke.  As she says in her introduction to the three articles, they cover the big three paediatric problems that historically have caused a degree of stress to the coronary arteries in the general orthopaedic surgeon when on call. These three articles cover supracondylar fractures, infection in the paediatric patient and open tibial fractures.  They’re excellent articles for both general and specialist orthopaedic surgeons alike and hopefully there’s something for everyone in the articles.

I do hope you enjoy the June edition of the JTO and let us hope for a quieter more peaceful summer.

Simon Hodkinson, Vice President Elect




Improving breast radiation protection for female orthopaedic surgeons

1.  Breast cancer statistics [Internet]. Cancer Research UK. 2018 [cited 2023 Jan 31]. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-      type/breast-cancer

2.  Rummel S. Tumour location within the breast: Does tumour site have prognostic ability? ecancer [Internet]. 2015 Jul 13 [cited 2022 Nov 7];9. Available from: http://www.ecancer.org/journal/9/full/552-tumour-location-within-the-breast-does-tumour-site-have-prognostic-ability.php

3.  Ronckers CM, Erdmann CA, Land CE. Radiation and breast cancer: a review of current evidence. Breast Cancer Res. 2004 Feb;7(1):21.

4.  Chou LB, Chandran S, Harris AHS, Tung J, Butler LM. Increased Breast Cancer Prevalence Among Female Orthopedic Surgeons. Journal of Women’s Health. 2012 Jun;21(6):683–9.

5.  Chou LB, Lerner LB, Harris AHS, Brandon AJ, Girod S, Butler LM. Cancer Prevalence among a Cross-sectional Survey of Female Orthopedic, Urology, and Plastic Surgeons in the United States. Women’s Health Issues. 2015 Sep;25(5):476–81.

6.  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. JAAOS Glob Res Rev [Internet]. 2022 May [cited 2022 Oct 31];6(5). Available from: https://journals.lww.com/10.5435/JAAOSGlobal-D-22-00031

7.  Linet MS, Kim KP, Miller DL, Kleinerman RA, Simon SL, de Gonzalez AB. Historical Review of Occupational Exposures and Cancer Risks in Medical Radiation Workers. Radiation Research. 2010 Dec;174(6b):793–808.

8.  Preston DL, Kitahara CM, Freedman DM, Sigurdson AJ, Simon SL, Little MP, et al. Breast cancer risk and protracted low-to-moderate dose occupational radiation exposure in the US Radiologic Technologists Cohort, 1983–2008. Br J Cancer. 2016 Oct;115(9):1105–12.

9.  Wang JX, Zhang LA, Li BX, Zhao YC, Wang ZQ, Zhang JY, et al. Cancer incidence and risk estimation among medical x-ray workers in China, 1950-1995. Health Phys. 2002 Apr;82(4):455–66.

10. Jartti P, Pukkala E, Uitti J, Auvinen A. Cancer incidence among physicians occupationally exposed to ionizing radiation in Finland. Scand J Work Environ Health. 2006 Oct;32(5):368–73.

11. Swergold N, Murthy V, Chamberlain RS. Males at High Risk for Breast Cancer: Who Are They and How Should We Screen Them? SS. 2014;05(07):320–31.

12. Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. Lancet. 2006 Feb 18;367(9510):595–604.

13. Valone LC, Chambers M, Lattanza L, James MA. Breast Radiation Exposure in Female Orthopaedic Surgeons. Journal of Bone and Joint Surgery. 2016 Nov 2;98(21):1808–13.

14. Van Nortwick SS, Leonard DA, Finlay AK, Chou L, Valone LC. Methods for Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons. Journal of Bone and Joint Surgery. 2021 Sep 1;103(17):1646–51.

Building a culture of safety and health at work

  1. Ryu R et al. Are we putting ourselves in danger? Occupational hazards and job safety for orthopaedic surgeons. J Orthop 2021; 24: 96-101. 
  1. Patel K et al. Occupational hazards for the practicing orthopaedic surgeon: A standard review. J Am Acad Orthop Surg 2022; 30(7): 607-616. 
  1. The National Institute for Occupational Safety and Health (NIOSH). Hierarchy of Controls | NIOSH | CDC 
  1. Raza M et al. Radiation in orthopaedics (RIO) study: A national survey of UK orthopaedic surgeons. Br J Radiol 2021; 94(1125). 
  1. Health and Safety Executive. Health and Safety: Ionising Radiation (hse.gov.uk) 
  1. Mastrangelo G et al. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med 2005; 55(6): 498-500. 
  1. Chou LB et al. Prevalence of cancer in female orthopaedic surgeons in the United States. J Bone Joint Surg Am 2010; 92(1): 240-244. 
  1. Hamilton A et al. Childbearing and pregnancy characteristics of female orthopaedic surgeons. J Bone Joint Surg Am 2012; 94(11). 
  1. Zadeh HG et al. Ionising radiation. Are orthopaedic surgeons’ off-spring at risk? Ann R Coll Surg Engl 1997; 79(3): 214-20. 
  1. Rampersaud YR et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine 2000; 25: 2637-2645. 
  1. Noordeen MH. Hazard of ionising radiation to trauma surgeons: Reducing the risk. Injury 1993; 24(8): 562-564. 
  1. Vosbikian MM. Radiation exposure to hand surgeons’ hands: A practical comparison of large and Mini C-arm fluoroscopy. J Hand Surg 2014; 39(9): 1805-1809. 

Non-selective state schools engagement programme

  1. Selection Alliance 2019 Report: An update on the Medical Schools Council’s work in selection and widening participation 
  1. The Class Ceiling. Sam Friedman and Daniel Laurison.  Policy Press 2000 
  1. www.ons.gov.uk/surveys/inforationforhouseholdsandindividuals/householdandindividualsurveys/labourforcesurvey 
  1. Royal College of Surgeons of England. National Undergraduate Currriculum. 2015 
  1. Sutton PA, Mason J, Vimalachandran, McNally S.  Attitudes, motivators, and barriers to a career in surgery: a national study of UK undergraduate medical students. J Surg Educ. 2014; 71:662-667 
  1. Davis CR, Toll EC, Bates AS, Cole MD, Smith FCT. Surgical and procedural skills training at medical school - a national review. Int J Sure 2014; 12:877-882 
  1. Hospital outpatient activity 2012-13. Hospital Episode Statistics. NHS Digital. 
  1. www.aaos.org 
  1. Diversity Matters.  McKinsey & Company. 2015 

Clinical guidelines and the standard of care: Part 1

1. Samanta A, Mello M, Foster C, Tingle J, Samanta J.  “The role of clinical guidelines in medical negligence litigation: A shift from the Bolam standard.” (2006) 14(3) Medical Law Review 321-366.

2. Samanta A, Mello M, Foster C, Tingle J, Samanta J.  “The role of clinical guidelines in medical negligence litigation: A shift from the Bolam standard.” (2006) 14(3) Medical Law Review, at 359.

3. Bolam v Friern Hospital Management Committee [1957] 2 All ER 118.

4. Bolitho v City and Hackney Health Authority (1997) 4 All ER 771.

5. Daubert v Merrell Dow Pharmaceuticals Inc 509 US 579 (1993).

6. Montgomery v Lanarkshire Health Board (2015) UKSC 11.

7. Royal College of Obstetricians and Gynaecologists.  “Green Top Guideline No. 42.  Shoulder dystocia.”  (2nd edn. London RCOG 2012)

8. National Institute for Health and Care Excellence.  “Clinical Guideline 132: Caesarean Section.”  2011;  National Institute for Health and Care Excellence.  “Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period.” 2015.

9. Montgomery J  and Montgomery E,  “Montgomery on informed consent: an inexpert decision?” (2016) 42(2) Journal of Medical Ethics 89-94

10. National Institute for Health and Care Excellence.  “Guidance and advice list.” https://www.nice.org.uk/guidance/published?type=cg

11. British Orthopaedic Association. “Standards for Trauma.”  https://www.boa.ac.uk/standards-guidance/boasts.html

12. British Association of Plastic, Aesthetic and Reconstructive Surgeons.  “Open fractures of the lower limb.”  2009  http://www.bapras.org.uk/professionals/clinical-guidance/open-fractures-of-the-lower-limb

13. Getting It Right First Time.  https://gettingitrightfirsttime.co.uk/

14. Getting It Right First Time.  https://gettingitrightfirsttime.co.uk/cross-cutting-stream/litigation/

15. Tornetta P, Ricci W, Court-Brown CM, McQueen MM, McKee M.  Rockwood and Green's Fractures in Adults.  (9th edn.  Netherlands: Wolters Kluwer, 27 March 2019).

16. British Orthopaedic Association. “Standards for Trauma.”  https://www.boa.ac.uk/standards-guidance/boasts.html

17. Professor Keith Willett is currently Director of Acute Care to NHS England.

18. Professor Chris Moran is currently National Clinical Director for Trauma to NHS England.

19. Based on email correspondence with past President of the British Orthopaedic Association, Bob Handley, dated 6 August 2019.

20. The Trauma Audit & Research Network.  https://www.tarn.ac.uk/

21. Based on an interview with Professor Chris Moran, National Clinical Director for Trauma to NHS England and Professor of Orthopaedic Trauma Surgery, Nottingham University Hospitals NHS Trust, at Queen's Medical Centre Nottingham, on 10 December 2019.

22. Based on email correspondence with past President of the British Orthopaedic Association, Bob Handley, dated 6 August 2019.

23. British Association of Plastic, Aesthetic and Reconstructive Surgeons.  “Open fractures of the lower limb.”  2009  http://www.bapras.org.uk/professionals/clinical-guidance/open-fractures-of-the-lower-limb

Open tibial fractures in children: are they really just little adults?

1. National Institute for Health and Care Excellence. (2022). Fractures (complex): assessment and management [NICE Guideline No. 37]. https://www.nice.org.uk/guidance/ng37

2.  British Orthopaedic Association. (2009). BOAST 4: The management of severe open lower limb fractures. 

3.  Arnez ZM, Khan U, Tyler MP. Classification of soft-tissue degloving in limb trauma. J Plast Reconstr Aesthet Surg. 2010 Nov;63(11):1865-9. doi: 10.1016/j.bjps.2009.11.029. Epub 2010 Jan 6. PMID: 20056504.

4.  Emam A, Machhada A, Tilston T, Colavitti G, Katsanos D, Chapman T, Wright T, Khan U. Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures. Injury. 2021 Jun;52(6):1625-1628. doi: 10.1016/j.injury.2021.02.013. Epub 2021 Feb 11. PMID: 33648742 

5.  Jones CM, Roberts JM, Sirlin EA, Cavanaugh GA, Anagnostakos JP, Hauck RM, Spence Reid J. Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures. J Plast Reconstr Aesthet Surg. 2021 Nov;74(11):2933-2940. doi: 10.1016/j.bjps.2021.03.105. Epub 2021 Apr 20. PMID: 34049839. 

6.  Monsell FP, Howells NR, Lawniczak D, Jeffcote B, Mitchell SR. High-energy open tibial fractures in children: treatment with a programmable circular external fixator. J Bone Joint Surg Br. 2012 Jul;94(7):989-93. doi: 10.1302/0301-620X.94B7.28333. PMID: 22733958. 

7.  Andreacchio A, Alberghina F, Marengo L, Canavese F. Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome. Musculoskelet Surg. 2019 Apr;103(1):23-30. doi: 10.1007/s12306-018-0570-8. Epub 2018 Oct 11. PMID: 30311075. 

8.  Pennock AT, Bastrom TP, Upasani VV. Elastic Intramedullary Nailing Versus Open Reduction Internal Fixation of Pediatric Tibial Shaft Fractures. J Pediatr Orthop. 2017 Oct/Nov; 37(7):e403-e408. doi: 10.1097/BPO.0000000000001065. PMID: 28777278. 

9.  Smith JRA, Fox CE, Wright TC, Khan U, Clarke AM, Monsell FP. Orthoplastic management of open tibial fractures in children : a consecutive five-year series from a paediatric major trauma centre. Bone Joint J. 2021 Jun;103-B(6):1160-1167. doi: 10.1302/0301-620X.103B6.BJJ-2020-2085.R1. PMID: 34058876.