01 Sep 2019

Volume 7 Issue 3


From the Executive Editor

No success without succession; whether it pertains to a species, a religion, an association, a profession or a speciality, this adage highlights the risk of aging  without renewal. T&O currently has an environmental niche and there is a young generation who could populate it. However, it is probably better to plan succession than to presume it. We should continue to demonstrate the need for, and value of T&O surgery, whilst also making it look attractive to potential successors.

A constructive response to problems of patient care will maintain the respect and support of patients and community, and consequently secure the niche those groups allow us to occupy. Learning lessons from the setback of being presented with adverse observational data is a presumed consequence of registries.  Identifying problems should stimulate progress, not entrenched defence; the article on ‘The experience of an outlying unit…’ (page 36) exemplifies this. This  responsive approach to problems can be generalised and an initiative to collate and learn from litigation data has led GIRFT to produce new “BOAST type” guidance for operating theatre record keeping (page 46) to make practice more resilient.

We can revise and smooth the pathway for our successors. The article ‘New era in T&O Training’ (page 58) introduces the changes in training coming along with the new curriculum. A competency rather than a time based approach will be followed. New techniques and technologies also allow new approaches to training and we look at the impact of Simulation (page 54).

The outward concepts and attitudes of an organisation may evolve spontaneously, but what might be regarded as its organisational DNA needs positive action to change or it will lag behind and become outdated. Phil Turner describes the structural changes to committees and strategies that are being introduced to accommodate and allow the BOA to progress (page 10).

An advantage of our in-house journal is that we can be a little irreverent. Illustrating an article on clinical photography with lamb chops (page 48) may seem childish but is practical, cheap and may deliver a message in a way which sticks.

‘Humorous’ messages or phrases can stick when unwanted too. We T&O surgeons may view ourselves as being responsive and caring, but sadly these views may not to be shared by all. Like it or not there is a ‘humorous’ stereotype of an Orthopod which is not necessarily attractive to the public or our potential successors. Recognising the existence of such stereotypes is a start but not an end; there are three articles relating to this (pages 40-43). To broaden our appeal to potential successors we need change our image, not a photoshop patch up, but where necessary addressing underlying, uncomfortable truths.

Should no-one follow us into T&O what would happen; nature abhors a vacuum. Indeed, a vacuum may well be a problem for the profession but not necessarily for an individual patient. Demonstrating this, the specialty section gives three perspectives on negative pressure wound therapy (pages 64-73). No success without succession. Maintain the niche with adaptability and responsiveness, and generate wider enthusiasm by consigning restrictive and unattractive  stereotypes to history. Progress and reward should depend on competency not ‘sucking up’, unless of course the objective is wound healing.


Bob Handley, Vice President Elect


Subspecialty Section



Unconscious Bias: The Trainee Experience

  1. Subramanian P, Kantharuban S, Subramian V et al ‘Orthopaedic Surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study’, BMJ 2011; 343:d7506
  2. Moberly T ‘Number of Women entering medical school rises after decade of decline’, BMJ 2018; 360:k254
  3. www.bota.org.uk/women-in-surgery
  4. https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/good-practice-guides/avoiding-unconscious-bias/

Why do Orthopaedic Surgeons have a ‘stupid’ stereotype?

1. This is going to hurt, Secret diaries of a junior doctor, Author Adam Kay, Picador 2018, ISBN 978-1-5098-5863-7

2. Oxtoby K, Don the classic speciality stereotypes still hold true for todays doctors?  Br Med J; 347:f7454, 2013

3. Brenkel IJ, Pearce M, GreggPJ, A cracking complication of hemi-arthroplasty of the hip. Br Med J (Clinical Res Ed) 293; 1648, 1986

4. Fox JS, Bell GP, Sweeney PJ, Are orthopaedic surgeons really gorillas, Br Med J, 301: 1425-6, 1990

5. Subramian P, Kantharuban S, Subramanian V et al, Orthopaedic surgeons, strong as an ox and almost twice as clever? Multicentre prospective comparative study. Br Med J; 347: f7454, 2013

6. Barrett DS, Are orthopaedic surgeons gorillas? Br Med J; 297: 1638-9, 1988

Learning from clinical negligence claims; GIRFT tries BOASTing too

  1. Machin JT, Briggs TWR (2014) Litigation in trauma and orthopaedic surgery. J Trauma Orthop 02:32–38
  2. NHSResolution (2019) Annual Report and Accounts 2018/19
  3. House of Commons (2017) Managing the costs of clinical negligence in trusts. Rep by Comptrol Audit Gen. doi: 10.12968/bjon.2018.27.2.102
  4. Hutton M, (2019) Spinal Services GIRFT National Specialty Report
  5. Machin JT, Hardman J, Harrison W, Briggs TWR, Hutton M, Can Spinal Surgery in England be saved from litigation: A review of 978 clinical negligence claims against the NHS. European Spine Journal 2018 Nov;27(11):2693-2699.

Measuring the educational impact of simulation training in Trauma and Orthopaedics

1.  Kirkpatrick, D., Techniques for evaluating training programmes. Journal of American Society for Training and Development, 1959. 13(11): p. 11-12.

2.  Tsui, A.S. and B. Barry, Interpersonal Affect and Rating Errors. The Academy of Management Journal, 1986. 29(3): p. 586-599.

3.  Govaerts, M.J.B., et al., Workplace-based assessment: effects of rater expertise. Advances in Health Sciences Education, 2011. 16(2): p. 151-165.

4.  Christian, M.W., et al., Construct Validation of a Novel Hip Fracture Fixation Surgical Simulator. The Journal of the American Academy of Orthopaedic Surgeons, 2018. 26(19): p. 689-697.

5.  Khanduja, V., J.E. Lawrence, and E. Audenaert, Testing the Construct Validity of a Virtual Reality Hip Arthroscopy Simulator. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2017. 33(3): p. 566-571.

6.  Dosis, A., et al., Synchronized video and motion analysis for the assessment of procedures in the operating theater. Arch Surg, 2005. 140(3): p. 293-9.

7.  Colaco, H.B., et al., Construct Validity, Assessment of the Learning Curve, and Experience of Using a Low-Cost Arthroscopic Surgical Simulator. Journal of Surgical Education, 2017. 74(1): p. 47-54.

8.  VanHeest, A., et al., Objective structured assessment of technical skill in upper extremity surgery. The Journal of hand surgery, 2012. 37(2): p. 332-4.

9.   Van Heest, A., et al., Assessment of technical skills of orthopaedic surgery residents performing open carpal tunnel release surgery. The Journal of bone and joint surgery. American volume, 2009. 91(12): p. 2811-7.

10.  Martin, K.D., et al., Shoulder arthroscopy simulator performance correlates with resident and shoulder arthroscopy experience. The Journal of bone and joint surgery. American volume, 2012. 94(21): p. e160.

11.  Martin, K.D., et al., Arthroscopic basic task performance in shoulder simulator model correlates with similar task performance in cadavers. The Journal of bone and joint surgery. American volume, 2011. 93(21): p. e1271-5.

12.  Morgan, M., et al., Current Status of Simulation-based Training Tools in Orthopedic Surgery: A Systematic Review. Journal of Surgical Education, 2017. 74(4): p. 698-716.

13.  Akhtar, K., et al., Training safer orthopedic surgeons. Construct validation of a virtual-reality simulator for hip fracture surgery. Acta orthopaedica, 2015. 86(5): p. 616-21.

14.  Burns, G.T., et al., Evaluating Internal Fixation Skills Using Surgical Simulation. The Journal of bone and joint surgery. American volume, 2017. 99(5): p. e21.

15.  Gail M. Sullivan, Deconstructing Quality in Education Research. Journal of Graduate Medical Education, 2011. 3(2): p. 121-124.

16.  Department of Health., A Framework for Technology Enhanced Learning. 2011: London.

17.  General Medical Council, The Trainee Doctor. 2011: London.

A New Era in T&O Training

1. Gruppen LD, Ten Cate O, Lingard LA, Teunissen PW, Kogan JR. Enhanced Requirements for Assessment in a Competency-Based, Time-Variable Medical Education System. Acad Med. 2018 Mar;93(3S Competency-Based, Time-Variable Education in the Health Professions):S17-S21.

2. Shalhoub J, Santos C, Bussey M, Eardley I, Allum W. A Descriptive Analysis of the Use of Workplace-Based Assessments in UK Surgical Training. J Surg Educ. 2015 Sep-Oct;72(5):786-94.

3. Scarff CE, Bearman M, Chiavaroli N, Trumble S. Trainees’ perspectives of assessment messages: a narrative systematic review. Med Educ. 2019 Mar;53(3):221-233. doi: 10.1111/medu.13775. Epub 2019 Jan 22.

4. Alazzawi S, Berstock J. Use of work-based assessments in postgraduate medical education. Br J Hosp Med (Lond). 2019 May 2;80(5):285-287.

5. Excellence by design: standards for postgraduate curricula (May 2017) https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/excellence-by-design

6. Generic professional capabilities framework (May 2017) https://www.gmc-uk.org/-/media/documents/generic-professional-capabilities-framework--0817_pdf-70417127.pdf

7. Good Medical Practice (March 2013) https://www.gmc-uk.org/-/media/documents/good-medical-practice---english-1215_pdf-51527435.pdf

8. Beard J, Bussey M. The Learning Agreement. Ann R Coll Surg Engl (Suppl) 2007; 89:234–235

Mode of action and clinical benefits of closed incision negative pressure: A literature review

  1. Javed AA, Teinor J, Wright M, Ding D, Burkhart RA, Hundt J, Cameron JL, Makary MA, He J, Eckhauser FE, Wolfgang CL, Weiss MJ. Negative Pressure Wound Therapy for Surgical-site Infections: A Randomized Trial. Ann Surg. 2019 Jun;269(6):1034-1040
  2. Horch R. et al Incisional negative pressure wound therapy for high-risk wounds Proceedings of the International Surgical Wound Forum 2014. Journal of Wound Care Vl 2 24 4, no 4, April 2015
  3. Dyck BA, Bailey CS, Steyn C, Petrakis J, Urquhart JC, Raj R, Rasoulinejad P. Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study. J Neurosurg Spine. 2019 May 10:1-10. doi: 10.3171/2019.2.SPINE18947.
  4. Cooper HJ, Bas MA. Closed-Incision Negative-Pressure Therapy Versus Antimicrobial Dressings After Revision Hip and Knee Surgery: A Comparative Study. J Arthroplasty. 2016 May;31(5):1047-52. doi: 10.1016/j.arth.2015.11.010. Epub 2015 Nov 26.
  5. Tran BNN, Johnson AR, Shen C, Lee BT, Lee ES. "Closed-Incision Negative-Pressure Therapy Efficacy in Abdominal Wall Reconstruction in High-Risk Patients: A Meta-Analysis". J Surg Res. 2019 Apr 19;241:63-71.
  6. Stannard JP, Robinson JT, Anderson ER, McGwin G, Jr., Volgas DA, Alonso JE. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2006 June 1;60(6):1301-6.
  7. Bonds, A.M., Novick, T.K., Dietert, J.B. et al. Incisional negative pressure wound therapy significantly reduces surgical site infection in open colorectal surgery. Dis Colon Rectum 2013; 56: 12, 1403–1408.
  8. Blum ML, Esser M, Richardson M, Paul E, Rosenfeldt FL. Negative pressure wound therapy reduces deep infection rate in open tibial fractures. J Orthop Trauma 2012;26:499–505.
  9. Reddix RN, Leng XI, Woodall J, et al. The effect of incisional negative pressure therapy on wound complications after acetabular fracture surgery. J Surg Orthop Adv 2010;19:91–97.
  10. Grauhan O, Navasardyan A, Hofmann M, et al. Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy. J Thorac Cardiovasc Surg 2013;145:1387–1392.
  11. Blackham AU, Farrah JP, McCoy TP, Schmidt BS, Shen P. Prevention of surgical site infections in high-risk patients with laparotomy incisions using negative-pressure therapy. Am J Surg 2013;205:647–654.
  12. Gomoll AH, Lin A, Harris MB. Incisional vacuum-assisted closure therapy. J Orthop Trauma 2006;20:705–709.
  13. Atkins BZ, Wooten MK, Kistler J, et al. Does negative pressure wound therapy have a role in preventing poststernotomy wound complications? Surg Innov 2009;16:140–146.
  14. Colli A, Camara ML. First experience with a new negative pressure incision management system on surgical incisions after cardiac surgery in high risk patients. J Cardiothorac Surg 2011;6:160.
  15. Milena Pachowsky, Johannes Gusinde, Andrea Klein, Siegfried Lehrl, Stefan Schulz-Drost, Philipp Schlechtweg, Johannes Pauser, Kolja Gelse, Matthias H Brem  Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty. Int Orthop 2012 Apr 15;36(4):719-22. Epub 2011 Jul 15.
  16. Nordmeyer, M., Pauser, J., Biber, R. et al. Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care. Int Wound J 2016; 13: 6, 1176–1179.
  17. Wilkes RP, Kilpadi DV, Zhao Y, Kazala R, McNulty A. Closed incision management with negative pressure wound therapy (CIM): biomechanics. Surg Innov 2012 March 1;19(1):67-75.
  18. Glaser DA, Farnsworth CL, Varley ES et al. Negative pressure therapy for closed spine incisions: A pilot study. Wounds 2012 November 1;24(11).
  19. Lessing MC, Stock KM, Kilpadi DV. A closed incision management system improves scar biomechanics in vivo. (Presented at the 21st Annual Meeting of the Wound Healing Society SAWC-Spring/WHS Joint meeting, April 14-17, 2011, Dallas, TX). Wound Repair and Regeneration 19[2], A33. 3-1-2011. Ref Type: Abstract
  20. Wilkes R, Zhao Y, Cunningham K, Kieswetter K, Haridas B. 3D strain measurement in soft tissue: demonstration of a novel inverse finite element model algorithm on MicroCT images of a tissue phontom exposed to negative pressure wound therapy. J Mech Behav Biomed Mater. 2008;2:272-287.
  21. Odland GF. Structure of the skin. In: Goldsmith LA, ed. Physiology, Biochemistry, and Molecular Biology of the Skin. Oxford, UK: Oxford University Press; 1991.
  22. John Loveluck, PhD, Tom Copeland, BSc, Jason Hill, PhD, Allan Hunt, MSc, and Robin Martin, PhD. Biomechanical Modeling of the Forces Applied to Closed Incisions During Single-Use Negative Pressure Wound Therapy
  23. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W.Vacuum-assisted closure: a new method for wound control
  24. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38:563-576.
  25. Kairinos N., Solomons M., Hudson D., Negative Pressure Wound Therapy I The paradox of Negative-Pressure Wound Therapy.  Journal of Plastic and Reconstructive Surgery, Vol 123, No 2. February 2009
  26. Paolo Erba, MD, Rei Ogawa, MD PhD1, Maximilian Ackermann, Avner Adini, PhD, Lino F Miele, MD, Pouya Dastouri, MD, Doug Helm, MD, Steven J Mentzer, MD, Robert J, D’Amato, MD PhD, George F Murphy, MD, Moritz A Konerding, MD, and Dennis P Orgill, MD PhD. Angiogenesis in Wounds Treated by Microdeformational Wound Therapy. Ann Surg. 2011 February ; 253(2): 402–409.
  27. Saxena SM, et al. Vacuum Assisted Closure: Microdeformations of Wounds and Cell Proliferation. Plastic & Reconstructive Surgery, 2004;114(5):1086-1095
  28. Greene AK, Puder M, Roy R, Arsenault D, Kwei S, Moses MA, Orgill DP. Microdeformational wound therapy: effects on angiogenesis and matrix metalloproteinases in chronic wounds of 3 debilitated patients. Ann Plast Surg. 2006 Apr;56(4):418-22.


Closed incision negative pressure wound therapy in orthopaedic surgery

1. A. Agarwal, ‘Management of Closed Incisions Using Negative-Pressure Wound Therapy in Orthopedic Surgery’, Plastic and Reconstructive Surgery, 2019, 21S-26S.

2. D. Nam et al., ‘The Use of Closed Incision Negative-Pressure Wound Therapy in Orthopaedic Surgery’, The Journal of the American Academy of Orthopaedic Surgeons, 26(9),2018, 295–302.

3. C. Willy et al, ‘Closed incision negative pressure therapy: international multidisciplinary consensus recommendations’, International Wound Journal, 14(2), 2017, 385–398.

4. L. X. Webb, ‘The Impact of Negative Pressure Wound Therapy on Orthopaedic Infection’, The Orthopedic Clinics of North America, 48(2), 2017, 167–179.

5. B. Allegranzi et al., ‘WHO Guidelines Development Group. (2016). New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective’, The Lancet. Infectious Diseases, 16(12), 2016, e288–e303.

6. J. Loveluck, ‘Biomechanical Modeling of the Forces Applied to Closed Incisions During Single-Use Negative Pressure Wound Therapy’, Eplasty, 16, 2016 ,e20.

Keeping the WOLLF from the door or WHISTful thinking?

1.      British Association of Plastic RaAS. Standards for the management of open fractures of the lower limb. BAPRAS/BOAST. 2009.

2.      Krug E, Berg L, Lee C, Hudson D, Birke-Sorensen H, Depoorter M, et al. Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011;42:S1-S12.

3.      Iheozor‐Ejiofor Z, Newton K, Dumville JC, Costa ML, Norman G, Bruce J. Negative pressure wound therapy for open traumatic wounds. Cochrane Database of Systematic Reviews. 2018(7).

4.      Achten J, Parsons NR, Bruce J, Petrou S, Tutton E, Willett K, et al. Protocol for a randomised controlled trial of standard wound management versus negative pressure wound therapy in the treatment of adult patients with an open fracture of the lower limb: UK Wound management of Open Lower Limb Fractures (UK WOLFF). BMJ Open. 2015;5(9).

5.      Costa ML, Achten J, Bruce J, et al. Effect of negative pressure wound therapy vs standard wound management on 12-month disability among adults with severe open fracture of the lower limb: The wollf randomized clinical trial. JAMA. 2018;319(22):2280-8.

6.      Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br. 2006;88(3):351-7.

7.      Tutton EA-OhooX, Achten J, Lamb SE, Willett K, Costa ML. Participation in a trial in the emergency situation: a qualitative study of patient experience in the UK WOLLF trial. (1745-6215 (Electronic)).

8.      Stannard JP, Volgas DA, McGwin G, 3rd, Stewart RL, Obremskey W, Moore T, et al. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma. 2012;26(1):37-42.

9.      Hyldig N, Birke-Sorensen H, Kruse M, Vinter C, Joergensen JS, Sorensen JA, et al. Meta-analysis of negative-pressure wound therapy for closed surgical incisions. Br J Surg. 2016;103(5):477-86.

10.   Webster J, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev. 2014;10:Cd009261.

11.   Karlakki SL, Hamad AK, Whittall C, Graham NM, Banerjee RD, Kuiper JH. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res. 2016;5(8):328–337. doi:10.1302/2046-3758.58.BJR-2016-0022.R1

12.       Pachowsky M, Gusinde J, Klein A, Lehrl S, Schulz-Drost S, Schlechtweg P, et al. Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty. International Orthopaedics. 2012;36(4):719-22.

13.       Pauser J, Nordmeyer M, Biber R, Jantsch J, Kopschina C, Bail HJ, et al. Incisional negative pressure wound therapy after hemiarthroplasty for femoral neck fractures - reduction of wound complications. Int Wound J. 2016;13(5):663-7.

14.       Walsh M, Srinathan SK, McAuley DF, Mrkobrada M, Levine O, Ribic C, et al. The statistical significance of randomized controlled trial results is frequently fragile: a case for a Fragility Index. Journal of Clinical Epidemiology. 2014;67(6):622-8.

15.       Achten J, Vadher K, Bruce J, Nanchahal J, Spoors L, Masters JP, et al. Standard wound management versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for major trauma to the lower limb—a two-arm parallel group superiority randomised controlled trial: protocol for Wound Healing in Surgery for Trauma (WHIST). BMJ Open. 2018;8(6):e022115.

16.       Masters JPM, Achten J, Cook J, Dritsaki M, Sansom L, Costa ML. Randomised controlled feasibility trial of standard wound management versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for hip fractures. BMJ Open. 2018;8(4):e020632.