01 Mar 2016

Volume 4 Issue 1


From the Editor

The first JTO of 2016 is here – lots to look forward to?  The Carter report has been heralded by politicians and the press.  Reading it there is a lot of influence from GIRFT.  That in itself shows that if the profession stands up takes action it has an effect.  I would argue that the thoughtful guidance on how to implement GIRFT produced by the BOA is actually the more important document, certainly for clinicians.

This issue of JTO is full of useful support to the clinician, not least in the peer-reviewed section (page 44) where the all-round thoroughness of revision knee surgery is so well explained.  The three main articles in this section are linked by issues faced by surgeons undertaking revision knee replacement.  In an era when implant technology has given us several solutions for both reconstruction and fixation, it is easy to overlook the essential topics of surgical exposure, debridement and antimicrobial therapies all of which need to be addressed to achieve success when managing prosthetic joint infection of the knee.

The data position statement (page 12) gives a wide view of a difficult area evolving in our practices.  Bullying in the work place challenges us to be aware of this problem (page 24).  The realities of evolving an orthopaedic career as a woman need to have a sense of focus (page 28).  For me, a major issue is the value of orthopaedics and I am sure you will see more about this as the year progresses.

A final word of thanks to Rhidian Morgan-Jones for his efforts as Guest Editor and a prompt to say there will be a prize from the Editorial Team for the first letter that arrives that adds meaningfully to the debates of this issue.  Of course the downside is that the arbiters of that will be the Editorial Team.


Ian Winson – BOA Vice President

Reference Lists


Current Status of Meniscal Reconstruction

1. Baker BE, Peckham AC, Pupparo F, Sanborn JC. Review of meniscal injury and associated sports. Am J Sports Med. 1985 Jan;13(1):1–4.  

2. Jameson SS, Dowen D, James P, Serrano-Pedraza I, Serrano-Pedraza D, Reed MR, et al. The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS. J Bone Joint Surg Br. British Editorial Society of Bone and Joint Surgery; 2011 Oct;93(10):1327–33.  

3. Smith NA, MacKay N, Costa M, Spalding T. Meniscal allograft transplantation in a symptomatic meniscal deficient knee: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2015 Jan;23(1):270–9.  

4. Papalia R, Franceschi F, Balzani LD, D'Adamio S, Maffulli N, Denaro V. Scaffolds for partial meniscal replacement: an updated systematic review. Br Med Bull. Oxford University Press; 2013 Mar 1;107(1):ldt007– 40.  

5. Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med. 1982 Mar;10(2):90–5.  

6. Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med. 1986 Jul;14(4):270–5.  

7. Pengas IP, Assiotis A, Nash W, Hatcher J, Banks J, McNicholas MJ. Total meniscectomy in adolescents: a 40year follow-up. J Bone Joint Surg Br. 2012 Dec;94(12):1649–54.  

8. Kempshall PJ, Parkinson B, Thomas M, Robb C, Standell H, Getgood A, et al. Outcome of meniscal allograft transplantation related to articular cartilage status: advanced chondral damage should not be a contraindication. Knee Surg Sports Traumatol Arthrosc. 2015 Jan;23(1):280–9.  

9. van der Wal RJP, Thomassen BJW, van Arkel ERA. Long-term clinical outcome of open meniscal allograft transplantation. Am J Sports Med. 2009;37(11):2134-2139.

10. Verdonk PC, Demurie A, Almqvist KF, Veys EM, Verbruggen G, Verdonk R. Transplantation of viable meniscal allograft. Survivorship analysis and clinical outcome of one hundred cases. J Bone Joint Surg Am. 2005;87(4):715-724.

11. Sekiya JK, Giffin JR, Irrgang JJ, Fu FH, Harner CD. Clinical outcomes after combined meniscal allograft transplantation and anterior cruciate ligament reconstruction. Am J Sports Med. American Orthopaedic Society for Sports Medicine; 2003 Nov;31(6):896–906.  

12. Ha JK, Shim JC, Kim DW, Lee YS, Ra HJ, Kim JG. Relationship Between Meniscal Extrusion and Various Clinical Findings After Meniscus Allograft Transplantation. Am J Sports Med. 2010 Dec 1;38(12):2448–55.  

13. Verdonk PCM, Verstraete KL, Almqvist KF, Cuyper K, Veys EM, Verbruggen G, et al. Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations. Knee Surg Sports Traumatol Arthr. 2006 Feb 7;14(8):694–706.  

Bullying and Harrassment in Surgery: Urgent Change Needed?

1. GMC. 2015. Dignity at Work Policy. [Online] Web: GMC Available: www.gmcuk.org/Dignity_at_work_policy.pdf_37469315.pdf [accessed 09-01-2016]

2. UK Government. 2010. Equality Act 2010. [Online] Web: UK Legislation. Available: www.legislation.gov.uk/ukpga/2010/15/contents [Accessed 09-01-2016].

3. WILD, J et al. 2015. Undermining and bullying in surgical training: A review and recommendations by the Association of Surgeons in Training. Int J Surg. Nov;23 Suppl 1:S5-9.

4. RCSEd. 2014. “Surgical Trainees 3x More Likely to Experience Bullying”. [Online]. Web: RCSEd. Available: www.rcsed.ac.uk/the-college/news/2014/may-2014/trainees-report-bullying.aspx [Accessed 09-01-2016].

5. GRIGG, M. 2015. Response to Age Letter. [Online]  Web: Royal Australasian College of Surgeons. Available: www.surgeons.org/media/21448806/120053_2015-03-10_ltr_m-grigg_editor_the_age.pdf Accessed; 09-01-15

6. GMC. 2013. National Training Survey 2013 Narrative Report: Undermining. [Online]. Web: GMC. Available: http://www.gmc uk.org/NTS_ 2013 _autumn_ report_undermining. pdf_54275779.pdf [Accessed: 09-01 2016]

7. GMC. 2014. National Training Survey 2014: Bullying and Undermining. [Online] Web: GMC. Available: http://www.gmc-uk.org/NTS_ bullying_and_ undermining_report_2014_ FINAL. pdf_58648010.pdf. [Accessed: 09-01-2016].

8. IMC. 2015. Your Training Counts Survey 2015. [Online] Web: IMC. Available: http://www.medicalcouncil.ie/News-and-Publications/Reports/Your-Training-Counts-2015-pdf-.pdf [Accessed 0901-2016].

9. SurgeonsNews (RCSEd). 2014. “We Are Taking On The Bullies”. [Online]. Web: Surgeons News. Available: http://www.surgeonsnews.com/trainees-students/we-are-taking-on-the-bullies [Accessed 09-01-2016].

10. TIMM, A. 2014.It would not be tolerated in any other profession except medicine’: survey reporting on undergraduates’ exposure to bullying and harassment in their first placement year. BMJ Open 4:e005140.

11. FAROOQ S, KANG S and RAMACHANDRAN M. 2009. Sex, Power and Orthopaedics. Journal of the Royal Society of Medicine, 102.4, 124–125.

12. BARLOW T, WIGHT A and BARLOW D. 2012. A cross-sectional study of aggression levels in physicians and orthopaedic surgeons: impact on specialty selection and training? JRSM Short Rep. 3(12):83.

13. RCSEd. 2014. Ibid.

14. KOTECH, S. 2015. Female Surgeons Face “Hostile Environment”. [Online] Web: BBC News. Available: http://www.bbc.com/news/health-34406443 [Accessed: 09-01-2016]

15. SHAH, J. 2015. How Can We Address Sexism in Medicine? [Online] Web: BMJ Blogs Available: http://blogs.bmj.com/bmj/2015/05/29/jyoti-shah-how-can-we-address-sexism-in-medicine/ [Accessed: 09-012016]

16. FITZGERALD, J et al. 2013. Gender-related perceptions of careers in surgery among new medical graduates: results of a cross-sectional study. Am J Surg 206(1): 112-9

17. SHAH, J. 2015. Ibid.

18. STRAEHLY, C and LONGO, P. 2006. Family issues affecting women in medicine, particularly women surgeons. Am J Surg. 192(5):695-8.

19. American Medical Association. 1992. Guidelines for establishing sexual harassment prevention and grievance procedures. JAMA. 268:273.

20. ZHUGE, Y et al. 2011. Is there still a glass ceiling for women in academic surgery? Ann Surg 253(4):637-43

21. LILLEBUEN, S. 2015. Senior Surgeon Gabrielle McMullin Stands by Advice for Female Doctors to Stay Silent on Sex Abuse. [Online] Web: Sydney Morning Herald. Available: http://www.smh.com.au/national/senior-surgeongabrielle-mcmullin-stands-by-advice-for-female-doctors-to-stay-silent-on-sex-abuse-20150307-13xzog.html [Accessed 09-01-2016]

22. FNAIS, N et al. 2014. Harassment and discrimination in medical training: a systematic review and meta-analysis. Academic Medicine 89(5), 817- 827. 

23. GIGA, S, HOEL, H and LEWIS, D. 2008. The Costs of Workforce Bullying, May 2008. Web: Workplace Violence Canada. Available: http://www.workplaceviolence.ca/sites/default/files/Giga%20et%20al.%20(2008)The%20costs%20of%20workplace%20bullying_0.pdf [Accessed: 09-01-2016

24. ACIK, Y et al. 2008. Experience of workplace violence during medical specialty training in Turkey. Occup Med (Lond). 58:361–366.

25. SurgeonsNews (RCSEd). 2014. Ibid.

26. WILD, J et al. 2015. Ibid.

27. RACS. 2014. Royal Australasian College of Surgeons Guidelines to Bullying and Harassment. [Online] Web: RACS Available: https://www.surgeons.org/media/21379791/art_2015-02-17_racs_028__bullying_and_harassment.pdf [Accessed: 09-01-16]

28. FRANCIS, R. 2013. Freedom to Speak Up – An Independent Review Into Creating and Open and Honest Reporting Culture Within The NHS. [Online] Web: UK National Web Archive. Available: http://webarchive.nationalarchives.gov.uk/20150218150343/https://freedomtospeakup.org.uk/wpcontent/uploads/2014/07/F2SU_web.pdf [Accessed 09-01-2016]

29. SurgeonsNews (RCSEd). 2014. Ibid.

30. LEWIS, V, SCHERL S and O’CONNOR, M. 2012. Women in Orthopaedics – Way Behind the Number Curve. J Bone Joint Surg Am. 2012 Mar 7;94(5):e30.

What Do We Know About the Value for Money of Orthopaedic Services Within the NHS?

1. Corbacho B. Orthopaedic research in the UK: the current state of the art. 2015;3(3):26-8.

2. Cochrane T, Davey R, Matthes Edwards S. Randomised controlled trial of the cost-effectiveness of waterbased therapy for lower limb osteoarthritis. Health Technology Assessment. 2005 2005/08/25;9(31):130.

3. Cooke M W, Marsh J L, Clark M, Nakash R, Jarvis R M. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technology Assessment. 2009 2009/03/16;13(13):144.

4. Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, et al. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess. 2015 2015/02/26;19(17).

5. Epps H, Ginnelly L, Utley M, Southwood T, Gallivan S. Is hydrotherapy cost effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritis. Health Technology Assessment. 2005 2005/10/03;9(39):76.

6. Gilbert F, Grant A, Gillan M, Vale L, Scott N. Does early magnetic resonance imaging influence management or improve outcome in patients referred to secondary care with low back pain? A pragmatic randomised controlled trial. Health Technology Assessment. 2004 2004/05/11;8(17):144.

7. Handoll H, Brealey S, Rangan A, Keding A, Corbacho B, Jefferson L, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess. 2015 2015/03/31;19(24).

8. Lamb S, Lall R, Hansen Z, Castelnuovo E, Withers E. A multicentred randomised controlled trial of a primarycare based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial. Health Technology Assessment. 2010 2010/09/23;14(41):281.

9. McCarthy C, Mills P, Pullen R, Richardson G, Hawkins N. Supplementation of a home-based exercise programme with a class-based programme for people with osteoarthritis of the knees: a randomised controlled trial and health economic analysis. Health Technology Assessment. 2004 2004/11/10;8(46):76.

10. 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 Technol Assess. 2014 2014/03/31;18(19).

11. Symmons D, Tricker K, Roberts C, Davies L, Dawes P. The British Rheumatoid Outcome Study Group (BROSG) randomised controlled trial to compare the effectiveness and cost-effectiveness of aggressive versus symptomatic therapy in established rheumatoid arthritis. Health Technology Assessment. 2005 2005/09/21;9(34):94.

12. Williams MA, Williamson EM, Heine PJ, Nichols V, Glover MJ, Dritsaki M, et al. Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomised controlled trial and economic evaluation. Health Technol Assess. 2015 2015/03/09;19(19). 

Introduction of a Novel Orthopaedic Weekend Handover System

1. ARORA V, JOHNSON J. 2006.A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 32: 646– 55 
2. Royal College of Physicians. 2010. A scoping project: Handover- the need and the best practice. London.  
3. JARDINE AGM, PAGE T, BETHUNE R, MOURANT P, DEOL P, BOWDEN C, DAHILL M, MISCHE C, CORNISH N, SANDERS V, LEE J. 2014.Bring on the weekend- Improving the quality of weekend handover. BMJ Qual Imp Rep; 2:2. 
4. COURT-BROWN C. 2009. Edinburgh Orthopaedic Trauma Unit.  [Online] web: Trauma.org. Available: http://www.trauma.org/index.php/resources/fellowship/313/ Accessed 13.08.14 
5. NHS Lothian. 2014. Services; Orthopaedics; who we are. [Online] web: NHS. Available:http://www.nhslothian.scot.nhs.uk/Services/AZ/Orthopaedics/Pages/WhoAreWe.aspx Accessed 13.08.14 
6. SOLET DJ, NORVELL JM, RUTAN GH, FRANKEL RM. 2005. Lost in translation: challenges and opportunities in physician-to-physician communication in patient handoffs. Acad Med; 80: 1094 – 9 
7. The Royal College of surgeons of England. March 2007. Safe handover: Guidance from the Working Time Directive working party. 

Where Expert Advice Goes (Seriously) Wrong: Recent Lessons From the Court Room

1. Para 11 Guidance for the Instruction of Experts in Civil Claims

2. Sardar v NHS Commissioning Board [2014] EWHC 38

3. Sardar – see above

4. EXP v Barker [2015] EWHC 1289

5. EXP – see above

6. The standard court direction in clinical negligence claims in the High Court includes the direction that: “13  Experts shall, at the time of producing their reports, produce a CV giving details of any employment or activity which raises a possible conflict of interest.”

7. Guidance for the Instruction of Experts in Civil Claims 2014 referred to in the Practice Direction to Part 35 of the Civil Procedure Rules 1998

8. Ali Shah v North West London Hospital NHS Trust [2013] EWHC 4088

9. Chappell v Newcastle upon Tyne Hospitals NHS Foundation Trust [2013] EWHC 4023

10. Where experts significantly alter their opinion, the legal team must inform the other parties as soon as possible –para 66 of the Guidance

11. Siegel v Pummell [2014] EWHC 4309

12. Shah – see above

13. An expression used by this author and explained in more detail  in Writing Medico-Legal Reports in Civil Claims – an essential guide (Eyre & Alexander)  (www.prosols.uk.com)

14. [1990] 1 Med LR 177 at 125