JTO - March 2019

06 Mar 2019

Volume 7 Issue 1


From the Executive Editor

In this edition of the JTO the articles have grown together as stepping stones to form a pathway through a T&O life.

The journey needs to be started; Chris Thornhill (page 30) describes how as a medical student a chance exposure to a subject met with enthusiasm may be the first step. However, the first line of the Emotional Side of Surgery (page 26) describes a stereotype of a surgeon, with declining competition for training posts we need to be wary of subconscious barriers and strive to change them.

Once surgical ambition is apparent we should be able to nurture it, in potential changes to T&O training the opportunity and importance of early commitment by both trainee and the training system is recognised. The Updated CCT guidelines (page 24) then then give us the framework to produce a day one consultant in T&O.

CCT completed and appointment gained we may prefer to ‘just get on with our job’, but change will continue. The discussion of the NICE VTE guideline (page 16) highlights how we may put ourselves in a position of having to accept change in a particular area of practice, but more importantly how by appropriate engagement we can influence and direct it. Phil Turner then looks in a stepwise fashion at how we may transform a whole service.

Reflection and assessment of self should always have been part of a professional life. The formalisation of this process into revalidation seemed a logical step to provide a structure for the benefit of patients and profession. Whether these objectives have been or are likely to be achieved is explored in general and in relation to T&O (pages 44-53).

The final step on the career pathway has been taken by some, and in this issue we pay our respects to them. One of those, Roger Checketts (page 54) takes us back to the first step on the path. He was the epitome of the orthopaedic enthusiast who if he spotted a spark of ability and desire in student or trainee could help ignite a career.


Bob Handley, Vice President Elect



Subspecialty Section


Reference Lists


The Emotional Side of Surgery


1. Peters K, Ryan M. Machismo in surgery is harming the speciality. BMJ. 2014; 348.

2. Knaus M. The surgeon stereotype. AAS Blog. 2018 (Accessed September 2018)(Available from: http://www.aasurg.org/blog/the-surgeon-stereotype/). 

3. Grossman R. The surgical personality: does it matter? RCS Bulletin. 2018; 100(3):130-132.

4. Oxtoby K. Do the classic specialty stereotypes still hold true for today’s doctors? BMJ. 2013; 347.

5. Arnold-Forster A. Operating with feeling: emotions in contemporary surgery. RCS Bulletin. 2018; 100 (1):12-14.

6. Marsh H. Do no harm: stories of life, death and brain surgery, London, Weidenfeld & Nicolson. 2014.

7. BOTA. Hammer it out. (Accessed September 2018)(Available from: http://www.bota.org.uk/hammer-it-out/).

8. BMA counselling and doctor advisor service. (Accessed September 2018)(Available from: https://www.bma.org.uk/advice/work-life-support/your-wellbeing/bma-counselling-and-doctor-advisor-service). 

9. NHS practitioner health programme. (Accessed September 218)(Available from: http://php.nhs.uk/). 

10. The point of care foundation. Schwartz rounds. (Accessed September 2018)(Available from: https://www.pointofcarefoundation.org.uk/our-work/schwartz-rounds/). 

11. Stacey M, Russ E, McCann A. Baker’s dozen of mental toughness: your stress management and resilience toolkit. (Accessed September 2018)(Available from: https://www.rcsed.ac.uk/media/415474/bakers-dozen-of-mental-toughness-stress-management-and-resilience-toolkit.pdf).

12. Women in surgery: press for success, London. (Accessed September 2018)(Available from: https://www.rcseng.ac.uk/news-and-events/events/calendar/women-in-surgery-press-for-success-conference/?_ga=2.57311274.1049846619.1522052141-782902769.1506941033&_gac=1.158083912.1521126216.CjwKCAjws6jVBRBZEiwAkIfZ2sYqBQL10fkd4a8LQgW4rjSXYEPFmmOdFveWhYeoamNJtxO6hC6FcBoCDnUQAvD_BwE).

13. Arnold-Forster A, Moulds A. Surgery and emotional health. RCS Bulletin. 2018; 100 (6):265-267. 

Operations I no longer do… Lumbar disc replacement



1. Putzier M, Funk JF, Schneider SV, Gross C, Tohtz SW, Khodadadyan-Klostermann C, Perka C, Kandziora F. Charite´ total disc replacement—clinical and radiographical results after an average follow-up of 17 years. European Spine Journal. 2006 Feb;15(2):183-95. 

2. Cui XD, Li HT, Zhang W, Zhang LL, Luo ZP, Yang HL. Mid- to long-term results of total disc
replacement for lumbar degenerative disc disease: a systematic review. J Orthop Surg Res. 2018 Dec 26;13(1):326. doi: 10.1186/s13018-018-1032-6.

3. NICE 2016. Low back pain and sciatica in over 16s: assessment and management. Available from: www.nice.org.uk/guidance/NG59

4. Berg S, Tullberg T, Branth B, Olerud C, Tropp H. Total disc replacement compared to lumbar fusion: A randomised controlled trial with 2-year follow-up. European Spine Journal. 2009; 18(10):1512-1519.

5. Gornet MF, Burkus JK, Dryer RF, Peloza JH. Lumbar disc arthroplasty with MAVERICK disc versus stand-alone interbody fusion: A prospective, randomized, controlled, multicenter investigational device exemption trial. Spine. 2011; 36(25):E1600-E1611

6. Hellum C, Johnsen LG, Storheim K, Nygaard OP, Brox JI, Rossvoll I et al. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ. 2011; 342:d2786

7. Jacobs W, Van der Gaag NA, Tuschel A, de KM, Peul W, Verbout AJ et al. Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane Database of Systematic Reviews. 2012; Issue 9:CD008326. DOI:10.1002/14651858.CD008326.pub2

8. Sasso RC, Foulk DM, Hahn M. Prospective, randomized trial of metal-on-metal artificial lumbar disc replacement: initial results for treatment of discogenic pain. Spine. 2008; 33(2):123-131

Assessing the quality of training delivered in Trauma and Orthopaedic training posts


1. Stammers J, Barry M. What makes a good training hospital? JTO 2015; 3(3): 42-44.

2. Tudor F, McConnell J, Smitham P, Palan J. Opinion of UK orthopaedic trainees regarding training, assessment and the trainee fee. Ann R Coll Surg Eng (Suppl) 2014; 96: e15-18.

3. Gill S, Campbell D. Promoting quality training and improving morale through a trainer-trainee dialogue and partnership. JTO 2018; 6(1): 76-77.

4. GMC. Promoting excellence: standards for medical education and training. London, GMC, 2015.

5. Hsiu-Fang H, Shannon S. Three approaches to qualitative content analysis. Qualitative Health Research. 2005 Nov; 15(9): 1277-1288.

6. Conference of Postgraduate Medical Deans (COPMeD). Gold Guide Seventh Edition. A Reference Guide for Postgraduate Specialty Training in the UK. COPMeD 2018.

7. Viney R, Rich A, Needleman S, Griffin A, Woolf K. The validity of the Annual Review of Competence Progression: a qualitative interview study of the perceptions of junior doctors and their trainers. J R Soc Med. 2017 Mar; 110(3): 110-117. 

8. GMC. Training environments 2017: Key findings from the national training surveys. London, GMC, 2017.

9. Joint Committee on Surgical Training. Third Annual Report of the JCST trainee survey.  London, JCST, 2017.

10. Jameson S, Lamb A, Wallace W et al. Trauma experience in the UK and Ireland: Analysis of orthopaedic training using the FHI eLogbook. Injury. 2008 Aug; 39(8): 844-852.

11. Wilson T, Sahu A, Johnson D, Turner P. The effect of trainee involvement on procedure and list times: a statistical analysis with discussion of current issues affecting orthopaedic training in UK. The Surgeon. 2010 Feb; 8(1): 15-9.

12. Royal College of Surgeons. ARCP Guidance to Trainees, Trainers and Assessment Panels June 2018.

13. Joint Committee on Intercollegiate Examinations - FRCS (Specialty) Examinations Section 2 - Trauma & Orthopaedic Regional Outcomes by Diet (CCT). London 2017. https://www.jcie.org.uk/content/content.aspx?ID=9

Early Diagnosis of Pyogenic Spinal Infection


1.  Darouiche RO: Spinal epidural abscess, N Engl J Med.  2006; 355: 2012-2020

2. Chen SH, Chang WN, Lu CH, Chuang YC, Lui CC, Chen SF, et al: The clinical characteristics, therapeutic outcome, and prognostic factors of non-tuberculous bacterial spinal epidural abscess in adults: a hospital-based study.  Acta Neurol Taiwan 2011;  20:107-113

3. Arko L, Quach E, Nguyen V, Chnag D, Sukul V, Kim BS:  Medical and surgical management of spinal epidural abscess:  A systematic review.  Neurosurg Focus 37(2):E4,2014

4. Soehle M, Wallenfang T.  Spinal epidural abscess:  clinical manifestations, prognostic factors, and outcomes.  Neurosurg 2002; 51:79-87

5. Davis DP, Salazar A, Chan TC, Vilke GM: Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain.  Clinical article.  J Neurosurg Spine 2011; 14:765-770

6. Connor DE Jr, Chittiboina P, Caldito G, Nanda A: Comparison of operative and non-operative management of spinal epidural abscess:  a retrospective review of clinical and laboratory predictors of neurological outcome.  Clinical article.  J Neurosurg Spine 2013; 19:119-127

7. Davis DP, Wold RM, Patel RJ, Tran AJ, Tokhi RN, Chan TC et al:  The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess.  J Emerg Med 2004; 26: 285-291

8. Heusner AP. Nontuberculous spinal epidural infection. N Engl J Med 1948; 239: 845-854

Revalidation: an evidence-based intervention?


1.    Donald A Schön. The Reflective Practitioner: Hoe professionals think in action. 1982 Basic Books, Inc. USA

2.    The Shipman Inquiry Reports (1-6)
https://webarchive.nationalarchives.gov.uk/20090808155110/http://www.the-shipman-inquiry.org.uk/reports.asp [Accessed 01/01/2019]

3.    Learning from Bristol: he Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995
https://webarchive.nationalarchives.gov.uk/20090811143822/http://www.bristol-inquiry.org.uk/final_report/the_report.pdf [Accessed 01/01/2019]

4.    Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (3 volumes)
 https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry [Accessed 01/01/2019]

5.    https://www.england.nhs.uk/medical-revalidation/about-us/what-is-revalidation/ [Accessed 12/12/2018]

6.    Revalidating doctors: ensuring standards, securing the future [Consultation]. GMC 2000 (June)

7.    Trust, assurance and safety: the regulation of health professionals in the 21st century. HM Government White Paper 2007 (February) https://www.gov.uk/government/publications/trust-assurance-and-safety-the-regulation-of-health-professionals-in-the-21st-century [Accessed 01/01/2019]

8.    The Medical Profession (Responsible Officers) Regulations 2010
http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents [Accessed 01/01/2019]

9.    Medical Act (1983)
http://www.legislation.gov.uk/ukpga/1983/54/contents [Accessed 01/01/2019]

10.    The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012
http://www.legislation.gov.uk/uksi/2012/2685/made [Accessed 01/01/2019]

11.    Supporting doctors, protecting patients: A consultation paper on preventing, recognising and dealing with poor clinical performance of doctors in the NHS in England. Department of Health 1999 (November)
https://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005688 [Accessed 01/01/2019]

12.    https://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/ALMD%205%202001.pdf [Accessed 01/01/2019]

13.    https://www.nhsemployers.org/your-workforce/pay-and-reward/medical-staff/consultants-and-dental-consultants/consultants-and-dental-consultants-tcs-handbook/consultant-contract-(2003) [Accessed 01/01/2019]

14.    https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/medical-validation-vijaya-nath-mar14.pdf [Accessed 01/01/19]

15.    https://www.gmc-uk.org/-/media/documents/taking-revalidation-forward---improving-the-process-of-relicensing-for-doctors_pdf-68683704.pdf [Accessed 01/01/19]

16.    https://www.gmc-uk.org/-/media/documents/rt---taking-revalidation-forward-action-plan---dc10267_pdf-71185817.pdf [Accessed 12/12/18]

17.    https://www.gmc-uk.org/-/media/documents/umbrella-report-final_pdf-74454378.pdf [Accessed 12/12/18]

18.    https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/revalidation-resources/monitoring-and-evaluating-revalidation/final-report-on-revalidation-published [Accessed 02/01/19]

19.    https://www.gmc-uk.org/news/news-archive/gmc-statement-on-the-publication-of-evaluating-the-regulatory-impact-of-medical-revalidation [Accessed 01/01/2019]

20.    https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/revalidation-resources/monitoring-and-evaluating-revalidation/updated-guidance-to-help-you-with-revalidation [Accessed 02/01/19]

21.    https://www.gmc-uk.org/search-results?searchText=revalidation%20data%20from%20the%20first%20five%20years [Accessed 03/02/2019]