04 Sep 2023

JTO - September 2023

Volume 11 Issue 3

From the Executive Editor

A warm, but currently damp welcome to the September, Congress edition of the JTO.

As I write this editorial, the orthopaedic and national media is reporting the sad loss of one of our young colleagues, cut down in his prime on holiday. A sad reminder of the frailty of human life. We also mourn the loss of Rolfe Birch, a true giant of our profession. Both are remembered in this edition and our sincere condolences go to the bereaved families.

Turning to this edition, the theme is on sustainability, reflecting the theme for this year’s Congress, ‘Sustainable Systems’.

I would like to start by congratulating the recipients of the BOA’s Honorary Fellowships for this year, listed here with their significant contributions to our profession.

Our first article is about advancing MSK health through research and innovation by Arash Angadji from ORUK. Many of us of a certain generation will remember Ronnie Furlong who was the driving force behind ORUK, and this is an important article at this time of huge waiting lists and an ever increasing workload in our profession, much of it driven by an ageing population and poor health.

Continuing the theme of the ORUK article, Chetan Khatri et al discuss how to introduce new technologies into our practice. This is a very relevant article, given the current issues we face with implant availability in the UK. The authors are all hugely experienced in both research and regulation of the subject.

Moving to the crux of this edition and this year’s Congress theme, there are a series of diverse articles, all with a common theme of sustainability in our profession.

First off is an article from Irrum Afzal et al, about the need to share best practice in sustainability in T&O, pointing out that the NHS is the largest single contributor to greenhouse emissions in the public sector and we in T&O are a big part of that statistic!

Sharon Scott then reviews the real and present issue of sustaining our trauma services against an avalanche of issue familiar to all of us. My generation starting to create a peak in the frail population at the same time as the trough in the younger age group that provide the care occurs. The perfect storm. The article reflects on the need to follow evidence-based practice as best we can, informed and supported by such initiatives as GIRFT in elective care.

We then move on to our invited section of articles on the subject of sustainability in T&O, edited by Steve Bendall in Brighton. These three thought-provoking articles start with a discussion of what sustainability means and what elements are realistic aims in our practice.

Benedict Rogers then covers the issue of ventilation in theatres and what is really required to reduce SSI’s, and whether the time has come to challenge the paradigm that all orthopaedic surgery has to be done in an ultraclean environment.

Finally, Hussameldin Nour et al looks at whether we should do a U-turn in our practice, and return to reusable gowns and drapes.

Three articles that look at what we can realistically do to change our carbon footprint in the practice of Trauma and Orthopaedic surgery.

This is a packed edition and I do hope all recipients find something of interest to themselves in these challenging times.

I look forward to seeing you at this year’s Congress in Liverpool.

 Simon Hodkinson, Vice President Elect


Subspecialty Section



How should we introduce new technologies into surgical practice? Part 1: The challenges of how we innovate now

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2.           Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. The Lancet. 2007;370(9597):1508-19.

3.           Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. New England Journal of Medicine. 1994;331(14):889-95.

4.           Biffl WL, Spain DA, Reitsma AM, Minter RM, Upperman J, Wilson M, et al. Responsible development and application of surgical innovations: a position statement of the Society of University Surgeons. J Am Coll Surg. 2008;206(6):1204-9.

5.           Muirhead-Allwood SK. Lessons of a hip failure. BMJ. 1998;316(7132):644.

6.           Riordan P, Bickler G, Lyons C. Lessons of a hip failure. Registers of joint replacement operations should be set up. BMJ. 1998;316(7149):1985.

7.           Beard DJ, Davies L, Cook JA, Stokes J, Leal J, Fletcher H, et al. Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial. The Lancet. 2022;400(10352):605-15.

8.           Newman SD, Atkinson HD, Willis-Owen CA. Anterior cruciate ligament reconstruction with the ligament augmentation and reconstruction system: a systematic review. Int Orthop. 2013;37(2):321-6.

9.           Tulloch SJ, Devitt BM, Porter T, Hartwig T, Klemm H, Hookway S, et al. Primary ACL reconstruction using the LARS device is associated with a high failure rate at minimum of 6-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3626-32.

10.         Rosas K, Hurley ET, Kennedy JG. Early Failures of Polyvinyl Alcohol Hydrogel Implant for the Treatment of Hallux Rigidus. Foot Ankle Orthop. 2020;5(4).

11.         Heneghan C, Thompson M, Billingsley M, Cohen D. Medical-device recalls in the UK and the device-regulation process: retrospective review of safety notices and alerts. BMJ open. 2011;1(1):e000155.

12.         French-Mowat E, Burnett J. How are medical devices regulated in the European Union? Journal of the Royal Society of Medicine. 2012;105(1_suppl):22-8.

13.         Adminstration UFaD. 510(k) Working Group Preliminary Report and Recommendations 2010 [Available from: https://www.fda.gov/files/about%20fda/published/CDRH-Preliminary-Internal-Evaluations----Volume-I--510%28k%29-Working-Group-Preliminary-Report-and-Recommendations.pdf.

14.         Dhruva SS, Bero LA, Redberg RF. Strength of study evidence examined by the FDA in premarket approval of cardiovascular devices. JAMA Network. 2009;302(24):2679-85.

15.         Kaplan AV, Baim DS, Smith JJ, Feigal DA, Simons M, Jefferys D, et al. Medical device development: from prototype to regulatory approval. Circulation. 2004;109(25):3068-72.

16.         Rogers L. Scandal of fruit netting ‘approved as surgical implant’: The Times; 2015 [Available from: https://www.thetimes.co.uk/article/scandal-of-fruit-netting-approved-as-surgical-implant-dvcqd2rt9mr.]

17.         Cumberlege J. First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review. Crown copyright. 2020.

18.         Ahmed I, Dhaif F, Khatri C, Parsons N, Hutchinson C, Staniszewska S, et al. The meniscal tear outcome (METRO) review: A systematic review summarising the clinical course and outcomes of patients with a meniscal tear. The Knee. 2022;38:117-31.

19.         Khatri C, Ahmed I, Parsons H, Smith NA, Lawrence TM, Modi CS, et al. The natural history of full-thickness rotator cuff tears in randomized controlled trials: a systematic review and meta-analysis. The American Journal of Sports Medicine. 2019;47(7):1734-43.

20.         Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology. 2010;49(12):2346-56.

21.         Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Rasmussen S, et al. Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials. Osteoarthritis Cartilage. 2018;26(9):1170-80.

22.         Larsen JB, Roos E, Laursen M, Holden S, Johansen MN, Rathleff MS, et al. Five-year follow-up of patients with knee osteoarthritis not eligible for total knee replacement: results from a randomised trial. BMJ Open. 2022;12(11):e060169.

23.         Metcalfe A, Parsons H, Parsons N, Brown J, Fox J, Mannion EG, et al. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START: REACTS): a group-sequential, double-blind, multicentre randomised controlled trial. The Lancet. 2022;399(10339):1954-63.

24.         McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC, et al. No surgical innovation without evaluation: the IDEAL recommendations. The Lancet. 2009;374(9695):1105-12.

25.         Craven J, Haddad FS, Perry DC. Introducing new procedures and devices: the IDEAL way. The British Editorial Society of Bone & Joint Surgery; 2021. p. 1326-7.

26.         Ben-Shlomo Y, Blom A, Boulton C, Brittain R, Clark E, Dawson-Bowling S, et al. The National Joint Registry 19th Annual Report 2022. 2022.

27.         Wilton T, Skinner JA, Haddad FS. Camouflage uncovered: what should happen next? Bone Joint J. 2023;105-b(3):221-6.

28.         New super registry: all implanted medical devices to be tracked 2023 [Available from: https://www.clinicalservicesjournal.com/story/41811/new-super-registry-all-implanted-medical-devices-to-be-tracked#:~:text=The%20Medical%20Device%20Outcome%20Registry%20will%20be%20responsive%20to%20concerns,and%20improve%20outcomes%20for%20patients.]

29.         The UK Confidential Reporting Programme for Aviation and Maritime  [Available from: http://www.chirp.co.uk/information-about.asp.]

30.         Horton R. Surgical research or comic opera: questions, but few answers. The Lancet. 1996;347(9007):984-5.

31.         Sayers A, Crowther MJ, Judge A, Whitehouse MR, Blom AW. Determining the sample size required to establish whether a medical device is non-inferior to an external benchmark. BMJ Open. 2017;7(8):e015397.

32.         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 Technology Assessment (Winchester, England). 2014;18(19):1.

33.         Getgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285-97.

34.         Kayani B, Tahmassebi J, Ayuob A, Konan S, Oussedik S, Haddad FS. A prospective randomized controlled trial comparing the systemic inflammatory response in conventional jig-based total knee arthroplasty versus robotic-arm assisted total knee arthroplasty. The Bone & Joint Journal. 2021;103(1):113-22.

35.         Kayani B, Konan S, Huq S, Tahmassebi J, Haddad F. Robotic-arm assisted total knee arthroplasty has a learning curve of seven cases for integration into the surgical workflow but no learning curve effect for accuracy of implant positioning. Knee Surgery, Sports Traumatology, Arthroscopy. 2019;27:1132-41.

36.         Griffin J, Davis ET, Parsons H, Mannion EG, Khatri C, Ellard DR, et al. Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial (RACER-knee): a study protocol. BMJ Open. 2023;13(6):e068255.

37.         Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, et al. Considerations and methods for placebo controls in surgical trials (ASPIRE guidelines). The Lancet. 2020;395(10226):828-38.

38.         Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. 2018;391(10118):329-38.

39.         Fernandez MA, Achten J, Parsons N, Griffin XL, Png M-E, Gould J, et al. Cemented or uncemented hemiarthroplasty for intracapsular hip fracture. New England Journal of Medicine. 2022;386(6):521-30.

40.         ROSSINI-2 2023 [Available from: www.birmingham.ac.uk/ROSSINI2.]

41.         Nuffield Department of Orthopaedics RaMS. REINFORCE  [cited 2023. Available from: https://www.ndorms.ox.ac.uk/situ/reinforce.]

Clinical guidelines and the standard of care: Part 2

  1. A Samanta, M Mello, C Foster, J Tingle, J Samanta.  “The role of clinical guidelines in medical negligence litigation: A shift from the Bolam standard.” (2006) 14(3) Medical Law Review 321-366
  2. British Orthopaedic Association. “Standards for Trauma.”  https://www.boa.ac.uk/standards-guidance/boasts.html
  3. 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
  4. Price v Cwm Taf University Health Board [2019] EWHC 938 (QB)
  5. National Institute for Health and Care Excellence.  “Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis.  Interventional procedures guidance 230.”  2007.  https://www.nice.org.uk/guidance/ipg230
  6. Price v Cwm Taf University Health Board [2019] EWHC 938 (QB), 18
  7. Price v Cwm Taf University Health Board [2019] EWHC 938 (QB), 21
  8. Michael Hill, “Two for the price of one” Parklane Plowden Chambers, 10 May 2019  https://www.mikehillbarrister.co.uk/post/2019/05/10/two-for-the-price-of-one
  9. P Tornetta, W Ricci, CM Court-Brown, MM McQueen, M McKee.  Rockwood and Green's Fractures in Adults.  (9th edn.  Netherlands: Wolters Kluwer, 27 March 2019)
  10. CA Rockwood Jr, DP Green, RW Bucholz.  Rockwood and Green's Fractures in Adults.  (6th edn.  Philadelphia: Lippincott, Williams and Wilkins, 2006)
  11. Getting It Right First Time.  “Best Practice for Hip Arthroplasty Surgery Documentation.”  2019  https://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/07/1a.-GIRFT-BHS-and-BOA-Best-Practice-hip-arthroplasty-documentation.pdf;  “Best Practice for Knee Arthroplasty Surgery Documentation.”  2019  https://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/07/1d.-GIRFT-BASK-and-BOA-Best-practice-knee-arthroplasty.pdf
  12.  Getting It Right First Time.  “Getting It Right in Orthopaedics: Reflecting on success and reinforcing improvement,”  2020, at 58-9  https://gettingitrightfirsttime.co.uk/wp-content/uploads/2020/02/GIRFT-orthopaedics-follow-up-report-February-2020.pdf
  13. British Orthopaedic Association.  “Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic.”  April 2020.  file:///C:/Users/User/Documents/PhD/Book%20proposal/BOA%20docs/COVID-19-BOASTs-Combined-FINAL.pdf


Blowing against the wind: the case for shifting the current paradigm on theatre ventilation

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  8. Chow TT, Yang XY. Ventilation performance in operating theatres against airborne infection: Review of research activities and practical guidance. J Hosp Infect. 2004;56(2):85–92.
  9. McHugh SM, Hill ADK, Humphreys H. Laminar airflow and the prevention of surgical site infection. More harm than good? Surgeon. 2015 Feb 1;13(1):52–8.
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  13. Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement? The ten-year results of the New Zealand joint registry. J Bone Jt Surg - Ser B. 2011;93 B(1):85–90.
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  20. Song K-H, Kim ES, Kim YK, Jin HY, Jeong SY, Kwak YG, et al. Differences in the risk factors for surgical site infection between total hip arthroplasty and total knee arthroplasty in the Korean Nosocomial Infections Surveillance System (KONIS). Infect Control Hosp Epidemiol [Internet]. 2012 Nov [cited 2023 Jun 23];33(11):1086–93. Available from: https://pubmed.ncbi.nlm.nih.gov/23041805/
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  24. Traversari AA, Bottenheft C, van Heumen SP, Goedhart CA, Vos MC. Effect of switching off unidirectional downflow systems of operating theaters during prolonged inactivity on the period before the operating theater can safely be used. Am J Infect Control. 2017;45(2):139-44.
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  26. Yau The use of a double heat pipe heat exchanger system for reducing energy consumption in an operating theatre - A full year energy model consumption simulation Energy & Buildings 40 Issue 5 2008 pages 917-25.

Reusable surgical gowns and drapes. Should we be adopting them?

  1. Kieser DC, Wyatt MC, Beswick A, Kunutsor S, Hooper GJ. Does the type of surgical drape (disposable versus non-disposable) affect the risk of subsequent surgical site infection? J Orthop. 2018;15(2):566-570.
  2. Rutala WA, Weber DJ. A review of single-use and reusable gowns and drapes in health care. Infect Control Hosp Epidemiol. 2001;22(4):248-257.
  3. Selcen Kilinc-Balci F. Evaluation of the physical performance of disposable isolation gowns. Am J Infect Control. Published online 2023. 
  4. Coulter WA, Chew-Graham CA, Cheung SW, Burke FJ. Autoclave performance and operator knowledge of autoclave use in primary care: a survey of UK practices. J Hosp Infect. 2001;48(3):180-185. 
  5. Song G, Cao W, Cloud RM. Medical textiles and thermal comfort. In: Handbook of Medical Textiles. Elsevier; 2011:198-218.
  6. Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg. 2012;114(5):1055 1066.
  7. Kieser DC, Wyatt MC, Beswick A, Kunutsor S, Hooper GJ. Reusable surgical gowns in an orthopaedic operating theatre: A cost-effectiveness study. Journal of Orthopaedics. 2018;15:566-570.
  8. AAMI level standards for gowns. Mun Global. Published December 10, 2018. Accessed June 23, 2023. https://munglobal.com.au/resources/knowledge-base/personal-protective-equipment/aami-level-standards-for-gowns/
  9. McQuerry M, Easter E, Cao A. Disposable versus reusable medical gowns: A performance comparison. Am J Infect Control. 2021;49(5):563-570.
  10. Karliner J, Slotterback S, Boyd R, Ashby B, Steele K. Health Care’s Climate Footprint, Climate-Smart Health Care Series Green Paper Number One. Health Care without Harm;2019.
  11. Sustainable Development Unit, Carbon Footprint update for NHS in England 2015. In: Sustainable Development Unit;2015.
  12. Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021;5(2):e84-e92. 
  13. Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of surgical operations: A systematic review: A systematic review. Ann Surg. 2020;272(6):986-995.
  14. Luschkova D, Ludwig A, Traidl-Hoffmann C. Climate crisis and its impact on human health. Dtsch Med Wochenschr. 2021;146(24-25):1636-1641. 
  15. Drew J, Christie SD, Tyedmers P, Smith-Forrester J, Rainham D. Operating in a climate crisis: A state-of-the-science review of life cycle assessment within surgical and anesthetic care. Environ Health Perspect. 2021;129(7):76001.
  16. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health. 2017;1(9):e381-e388. 
  17. Rizan C, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of products used in five common surgical operations: identifying contributing products and processes. J R Soc Med. Published online 2023:1410768231166135.
  18. Vozzola E, Overcash M, Griffing E. An environmental analysis of reusable and disposable surgical gowns. AORN J. 2020;111(3):315-325.
  19. Smith R. Spending ever more on the NHS and less on education: is this sensible? BMJ. 2023;381:916.
  20. Health expenditures in the U.S. – statistics & facts. Statista. Accessed June 23, 2023. https://www.statista.com/topics/6701/health-expenditures-in-the-us/
  21. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785. 
  22. Baykasoğlu A, Dereli T, Yilankirkan N. Application of cost/benefit analysis for surgical gown and drape selection: a case study. Am J Infect Control. 2009;37(3):215-226.
  23. Wedmore F. Reusable gowns and drapes in surgery could reduce carbon footprint, analysis shows. BMJ. 2023;381:853.