03 Mar 2023

Volume 11 Issue 1

From the Executive Editor

A warm welcome to this first edition of the JTO in 2023.

It has been unseasonably warm, but all is not well in the NHS with previously unheard of strikes from our nursing colleagues and at the time of writing, our junior medical colleagues voting overwhelmingly for industrial action – very challenging times lie ahead!

I am sure you are all aware of the sad loss of Dame Clare Marx in November last year. Much has been written about her in the orthopaedic and national literature, however we wanted to include in this edition a piece in celebration of her life (page 20), a life well-lived to say the least. We hope we have done justice to a remarkable human being.

This edition covers a number of topical issues that many of us are currently facing. Andrew Manktelow’s update (page 24) for those of us engaging in private practice is timely. PHIN has had a difficult gestation, but it is gathering pace and he reminds us that the CMRs ruling are a matter of law and cannot be ignored.

He appears again in this edition in conjunction with Bertie Leigh, BOA Council lay member and senior solicitor, to discuss the medico-legal implications of the pandemic and the current waiting lists (page 46). A sobering article to say the least.

Trainees from the Wessex rotation, lead by Adam Stoneham, present their experience in running a novel course in peer-to-peer learning from one’s mistakes (page 28). We all make them, but do we learn from them in a supportive environment? Frequently not, it would seem. Jonathan Howell and Mary Stocker discuss the development of the Exeter short stay arthroplasty unit (page 32). Whilst we may not all have the luxury of the real estate required, the article presents their experience of setting up such a unit and the considerable success they have had in ‘day case’ arthroplasty, and the advances in patient care as a result.

Further on, Paul Roberts discusses his considerable experience in developing and bringing to market new implants (page 38) and Bev Fitzsimons invites us to get off the production line, (page 42). A thought provoking article that reminds us that whilst an element of standardisation can help our practice and our patients, surgery is not a production line!

Last but by no means least, is this month’s speciality series of articles, this month covering spinal surgery. Introduced by Niall Eames discussing the evolution of spinal surgery in the UK (page 49), and followed by articles covering topics we can all be exposed to on call – those of cauda equina syndrome (page 50), spinal infection (page 54) and thoracolumbar fracture stability and its classification (page 58).

I hope you enjoy reading this March edition of the JTO.

 Simon Hodkinson, Vice President Elect


Subspecialty Section



‘Oops!’ Designing and implementing a novel peer-to-peer training session on learning from surgical mistakes

  1. Hardie JA, Brennan PA. Are You Surgically Current? Lessons from Aviation for Returning to Non-Urgent Surgery Following COVID-19. Br J Oral Maxillofac Surg. 2020;58(7):843-7.
  2. Kruger J, Dunning D. Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments. J Pers Soc Psychol. 1999;77(6):1121-34.
  3. Rahmani M. Medical Trainees and the Dunning-Kruger Effect: When They Don’t Know What They Don’t Know. J Grad Med Educ. 2020;12(5):532-4.
  4. Panagioti M, Khan K, Keers RN, et al. Prevalence, Severity, and Nature of Preventable Patient Harm across Medical Care Settings: Systematic Review and Meta-Analysis. BMJ. 2019;366:l4185.
  5. Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires a Systematic Review of Surgical Never Events. JAMA Surg. 2015;150(8):796-805.
  6. Yau CWH, Leigh B, Liberati E, et al. Clinical Negligence Costs: Taking Action to Safeguard NHS Sustainability. BMJ. 2020;368:m552.
  7. Lane J, Bhome R, Somani B. National Trends and Cost of Litigation in UK National Health Service (NHS): A Specialty-Specific Analysis from the Past Decade. Scott Med J. 2021;66(4):168-174.
  8. Bohnen JD, Lillemoe KD, Mort EA, Kaafarani HMA. When Things Go Wrong: The Surgeon as Second Victim. Ann Surg. 2019;269(5):808-9.
  9. The Kings Fund (2020). The NHS in a Nutshell: Activity in the NHS. Available at: www.kingsfund.org.uk/projects/nhs-in-a-nutshell/NHS-activity.
  10. Care Quality Commission (2018). Opening the Door to Change: NHS Safety Culture and the Need for Transformation. Available at: www.cqc.org.uk/sites/default/files/20181224_openingthedoor_report.pdf.
  11. Mushtaq F, O'Driscoll C, Smith F, et al. Contributory Factors in Surgical Incidents as Delineated by a Confidential Reporting System. Ann R Coll Surg Engl. 2018;100(5):401-5.
  12. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. 2009;360(5):491-9.
  13. Hardie JA, Oeppen RS, Shaw G, et al. You Have Control: Aviation Communication Application for Safety-Critical Times in Surgery. Br J Oral Maxillofac Surg. 2020;58(9):1073-7.
  14. Ellis R, Hardie JA, Summerton DJ, Brennan PA. Dual Surgeon Operating to Improve Patient Safety. Br J Oral Maxillofac Surg. 2021;59(7):752-6.
  15. Brierley C, Ellis L, Reid ER. Peer-assisted learning in medical education: A systematic review and meta-analysis. Med Educ. 2022;56(4):365-73.
  16. Dekker, Sidney. (2018). Just Culture: Restoring Trust and Accountability in Your Organization, Third Edition.

Cauda equina syndrome - an overview

  1. Lavy C, Marks P, Dangas K, Todd N. Cauda equina syndrome—a practical guide to definition and classification. Int Orthop. 2022;46(2):165-9.
  2. Hoeritzauer I, Wood M, Copley PC, Demetriades AK, Woodfield J. What is the incidence of cauda equina syndrome? A systematic review.  Journal of Neurosurgery: Spine SPI. 2020;32(6):832-41.
  3. Korse NS, Pijpers JA, van Zwet E, Elzevier HW, Vleggeert-Lankamp CLA. Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction. Eur Spine J. 2017;26(3):894-904.
  4. Rydevik B, Brown MD, Lundborg G. Pathoanatomy and pathophysiology of nerve root compression. Spine (Phila Pa 1976). 1984;9(1):7-15.
  5. Kapetanakis S, Chaniotakis C, Kazakos C, Papathanasiou J V. Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature. Folia Med (Plovdiv). 2017;59(4):377-86.
  6. Katzouraki G, Zubairi AJ, Hershkovich O, Grevitt MP. A prospective study of the role of bladder scanning and post-void residual volume measurement in improving diagnostic accuracy of cauda equina syndrome. Bone Jt J. 2020;102-B(6):677-82.
  7. Germon T, Ahuja S, Casey ATH, Todd NV, Rai A. British Association of Spine Surgeons standards of care for cauda equina syndrome. Spine J. 2015;15(3 Suppl):S2-S4
  8. Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976). 2000;25(12):1515-22.
  9. Todd NV, Dickson RA. Standards of care in cauda equina syndrome. Br J Neurosurg. 2016;30(5):518-22.
  10. Dhatt S, Tahasildar N, Tripathy SK, Bahadur R, Dhillon M. Outcome of spinal decompression in cauda equina syndrome presenting late in developing countries: Case series of 50 cases. Eur Spine J. 2011;20(12):2235-9.
  11. Gardner A, Gardner E, Morley T. Cauda equina syndrome: A review of the current clinical and medico-legal position. Eur Spine J. 2011;20(5):690-7.
  12. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disc herniation. J Bone Jt Surg Br. 2007;89(6):782-4.