03 Mar 2021

JTO - March 2021

Volume 9 Issue 1

From the Executive Editor

So the New Year certainly started with a bang... not due to the fireworks that had all been cancelled but courtesy of the ‘New Variant’ of an ‘Old Foe’. We were straight back into the thick of things and recovery is only just starting but there are some green shoots of spring appearing and reasons to be cheerful.

And what do you do when the nights are still long and work is not quite what you would like it to be… perhaps relax, put your feet up, curl up on the sofa and peruse a magazine or indeed the JTO? Well, I think you should... this edition is a pot pourri of interesting bits and pieces for you to dip in and out of. Like any good magazine, this edition of the JTO has a travel section where we will take you abroad (something we are all sadly missing) to Malawi, and a reflection by John Cashman on what has been achieved there during his tenure and beyond (page 36). Reflecting is a little bit of a theme this issue with Andrea Sott writing about her experiences not only, of rising to the challenges of a Medical Director post but in COVID-19 times too and the knock on effects of the ‘casual comment’ both good and bad (page 24). However, if its reflection you are after, look no further than the excellent article by Alister Hart looking at Ronnie Furlong the man and his hip (page 20) and going even further back, Ian Stephen our BOA Archivist, reflects on the origins or our Association (page 18). Looking at that menu and the signatures on it, always gives me a slight shiver down my spine.

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We can’t spend all our time in the past though so the challenges of being a trainee and where you are going to be trained is a constant concern at present – but hopefully the words by Ran Wei and Rob Gregory will be reassuring. I will take this opportunity to remind you that the new curriculum starts in six months time and trainers as well as trainees must be ready – this will involve you learning new things!

I know orthopods and there is only so much relaxing we can take so, of course, this JTO covers research and academia too – particularly clinically relevant research via our research champions and Hunterian Professors. Andrew Price and colleagues would like us to remember ‘it’s all about the knee’ – the soft tissues anyway, if not the joint! I think it’s all about the kids – but perhaps that will be for a future edition!

2020-21 has seen us embrace ‘alternative’ media, so if reading the JTO cover to cover is more than your attention span can cope with, I suggest you have a look at the Transient Journal webpages (www.boa.ac.uk/T-JTO) where you will find podcasts on knitting and pieces on constructing dinosaurs; perhaps they are vying for inclusion in the indicative procedures section of our new curriculum? Or maybe not… maybe it’s just for fun and happiness and we are all in favour of that at the moment.

As we head into Spring, and the future looks brighter please remember – “Great opportunities to help others seldom come, but small ones surround us every day.”– Sally Koch

I hope you enjoy this JTO and if you have any ideas for future articles, please let me know.

Deborah Eastwood, Vice President Elect


Subspecialty Section



Society for Back Pain Research (SBPR) update

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  2. Binch A, Snuggs J, Le Maitre CL. Immunohistochemical analysis of protein expression in formalin fixed paraffin embedded human intervertebral disc tissues. JOR Spine. 2020;3(3):e1098.
  3. Deane JA, Pavlova AV, Lim AKP, Gregory JS, Aspden RM, McGregor AH. Is intrinsic lumbar spine shape associated with lumbar disc degeneration? An exploratory study. BMC Musculoskelet Disord. 2020;21(1):433.
  4. Williamson E, Sanchez Santos MT, Morris A, Garrett A,Conway O, Boniface G, et al. The Prevalence of Back and Leg Pain and the Cross-sectional Association With Adverse Health Outcomes in Community Dwelling Older Adults in England. Spine (Phila Pa 1976). 2021;46(1):54-61.
  5. Roberts L, Osborn-Jenkins L. Delivering remote consultations: Talking the talk. Musculoskelet Sci Pract. 2020 [Epub ahead of print].
  6. Ryan C, Pope CJ, Roberts L. Why managing sciatica is difficult: patients’ experiences of an NHS sciatica pathway. A qualitative, interpretative study. BMJ Open. 2020;10:e037157.
  7. Shaheed CA, Machado GC, Underwood M. Drugs for chronic pain. Br J Gen Pract. 2020;70(701):576-7.
  8. Hallegraeff JM, Kan R, van Trijffel E, Reneman MF. State anxiety improves prediction of pain and pain-related disability after 12 weeks in patients with acute low back pain: a cohort study. J Physiother. 2020;66(1):39-44.
  9. Mannion AF, Mariaux F, Reitmeir R, Fekete TF, Haschtmann D, Loibl M, et al. Development of the "Core Yellow Flags Index" (CYFI) as a brief instrument for the assessment of key psychological factors in patients undergoing spine surgery. Eur Spine J. 2020;29(8):1935-52.
  10. Geraghty AWA, Roberts L, Hill J, Foster NE, Yardley L, Hat E, et al. Supporting self-management of low back pain with an internet intervention in primary care: a protocol for a randomised controlled trial of clinical and cost-effectiveness (SupportBack 2).  BMJ Open. 2020 10:e040543.

The posterior malleolar fracture – is the rule of a third or use of percentages an orthopaedic myth?

  1. Mason LW, Marlow WJ, Widnall J, Molloy AP. Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle. Foot Ankle Int. 2017 Nov;38(11):1229-35.
  2. Bartonicek J, Rammelt S, Kostlivy K, Vanecek V, Klika D, Tresl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135(4):505-16.
  3. Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg. 2018;138(9):1213-22.
  4. White TO. In defence of the posterior malleolus. Bone Joint J. 2018;100-B(5):566-9.
  5. Nelson MC, Jensen NK. The treatment of trimalleolar fractures of the ankle. Surgery, Gynecology and Obstetrics. Surg Gynecol Obstet. 1940;71:509-14.
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  7. Leung KH, Fang CX, Lau TW, Leung FK. Preoperative radiography versus computed tomography for surgical planning for ankle fractures. J Orthop Surg (Hong Kong). 2016;24(2):158-62.
  8. Black EM, Antoci V, Lee JT, Weaver MJ, Johnson AH, Susarla SM, et al. Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int. 2013;34(5):697-704.
  9. Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma. 1994;8(4):328-31.
  10. Sheikh HQ, Mills EJ, McGregor-Riley JC, Chadwick C, Davies MB. The effect of computerised tomography on operative planning in posterior malleolus ankle fractures. Foot Ankle Surg. 2020;26(6):676-80.
  11. Meijer DT, de Muinck Keizer RJ, Doornberg JN, Sierevelt IN, Stufkens SA, Kerkhoffs GM, et al. Diagnostic Accuracy of 2-Dimensional Computed Tomography for Articular Involvement and Fracture Pattern of Posterior Malleolar Fractures. Foot Ankle Int. 2016;37(1):75-82.
  12. Meijer DT, Doornberg JN, Sierevelt IN, Mallee WH, van Dijk CN, Kerkhoffs GM, et al. Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury. 2015;46(10):2024-9.
  13. Buchler L, Tannast M, Bonel HM, Weber M. Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma. 2009;23(3):208-12.
  14. Kumar A, Mishra P, Tandon A, Arora R, Chadha M. Effect of CT on Management Plan in Malleolar Ankle Fractures. Foot Ankle Int. 2018;39(1):59-66.
  15. Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of Posterior Malleolar Fractures of the Ankle. J Bone  Joint Surg Am. 2006;88(5):1085-92.
  16. Mason LW, Marlow WJ, Widnall J, Molloy AP. Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle. Foot Ankle Int. 2017;38(11):1229-35.
  17. Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma. 2020;11(3):375-9.
  18. Haraguchi N, Armiger RS. Mechanism of posterior malleolar fracture of the ankle: A cadaveric study. OTA International. 2020;3(2):e060.
  19. Gardner MJ, Brodsky A, Briggs SM, Lorich DG, Nielson JH. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Rel Res. 2006(447):165-71.
  20. Baumbach SF, Herterich V, Damblemont A, Hieber F, Böcker W, Polzer H. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury. 2019;50(2):564-70.
  21. Miller MA, McDonald TC, Graves ML, Spitler CA, Russell GV, Jones LC, et al. Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation. Foot Ankle Int. 2018;39(1):99-104.
  22. Fitzpatrick E, Goetz JE, Sittapairoj T, Hosuru Siddappa V, Femino JE, Phisitkul P. Effect of Posterior Malleolus Fracture on Syndesmotic Reduction: A Cadaveric Study. J Bone Joint Surg Am. 2018;100(3):243-8.
  23. Jayatilaka MLT, Philpott MDG, Fisher A, Fisher L, Molloy A, Mason L. Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture. Foot Ankle Int. 2019;40(11):1319-24.
  24. Odak S, Ahluwalia R, Unnikrishnan P, Hennessy M, Platt S. Management of Posterior Malleolar Fractures: A Systematic Review. J Foot Ankle Surg. 2016;55(1):140-5.
  25. Blom RP, Hayat B, Al-Dirini RMA, Sierevelt I, Kerkhoffs G, Goslings JC, et al. Posterior malleolar ankle fractures. Bone Joint J. 2020;102-b(9):1229-41.
  26. Mason LW, Kaye A, Widnall J, Redfern J, Molloy A. Posterior Malleolar Ankle Fractures: An Effort at Improving Outcomes. JBJS Open Access. 2019;Latest Articles.
  27. Jeyaseelan L, Bua N, Parker L, Sohrabi C, Trockels A, Vris A, et al. Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury. 2020 [Epub ahead of print].

The anatomy of an awesome randomised trial

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  7. Beard DJ, Rees JL, Cook JA, 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.
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  22. Costa ML, Achten J, Parsons NR, et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807.
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Surgical rationing in times of COVID-19 pandemic – how does it affect the Montgomery ruling and GMC guidance on consent?

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Arthroscopic menisectomy for isolated meniscal tears – changing practice

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  2. Khan KM. Deimplementing arthroscopy, improving concussion reporting and celebrating research quality. Br J Sports Med. 2020;54:1305-1306.
  3. Abram SGF, Beard DJ, Hing CB, Price AJ. Evidence update: A summary of new evidence to inform treatment decisions for patients with meniscal lesions. Knee. 2019;26(3):521-523.
  4. Abram SGF, Beard DJ, Price AJ. National consensus on the definition, investigation, and classification of meniscal lesions of the knee. Knee. 2018;25(5):834-840.
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  6. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up. BMJ. 2016;354:i3740.
  7. Abram SGF, Hopewell S, Monk AP, Bayliss LE, Beard DJ, Price AJ. Arthroscopic partial meniscectomy for meniscal tears of the knee: A systematic review and meta-analysis. Br J Sports Med. 2020;54(11):652-663.
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Is ACL repair possible?

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