joint 2014 (pdf)

JOINT 2014

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JOINT 1

Journal of Orthopaedic Surgeons in National Training

British Orthopaedic Trainees AssociationBritish Orthopaedic Association Offices35-43 Lincoln’s Inn FieldsLondon, WC2A 3PE020 7405 6507bota.org.uk

Chapters

Committee Reports and Profiles 4-21

Linkmen Reports 22-35

Educational Weekend 36-47

Reviews 48-61

Prizes and Bursaries 62-75

Education and Training 76-91

Dates for the Diary 92

JOINT4

Committee Reports and Profiles

Editor’s Report 7

President’s Report 8-9

Vice-President’s Report 10

Treasurer’s Report 11

Specialty Advisory Committees (SAC) Representative 12-13

British Medical Association (BMA) Representative 13

Junior Report 14

Academic Report 15

Northern Ireland Representative Report 16

Scottish Representative Report 16

Welsh Representative Report 17

Committee Profiles 18-21

JOINT6

ORS4502-BOTA-A4-outlined.indd 1 14/08/2014 09:57

JOINT 7

Welcome to this years edition of JOINT. The aim of the journal is to keep trainees up to date with the work of the committee but also to raise awareness of current topics that are relevant to all orthopaedic surgeons in training.

I would like to thank all those who contributed so many interesting articles to the journal. It was fascinating to read Richard Rawlins article on the history of BOTA and to see that the struggle to maintain quality of orthopaedic training continues much the same today as it did 30 years ago. One of the biggest training issues over the last year has been the ‘Shape of Training Review’ and there is a very good article on this in the education and training chapter. This chapter also introduces Wikipaedics and the British Orthopaedic Network Environment, two websites that will only add to the

improvement of training in the years to come. For those of you thinking of expanding your horizons there is food for thought in the review section with articles on the Royal Naval Reserves and Setting up a Medico-Legal Practice.

I would like to thank industry for continuing to support BOTA and allowing us to produce this publication annually. I would also like to thank Ruth Halliday who has supported me in the final copy editing of JOINT. Finally a big thank you to Adam Hylands, whose skills in graphic design have allowed us to produce this professional high quality publication.

I hope you enjoy reading on… I am off to practice my cognitive simulation!

Editor’s ReportAndy Hughes

Saturday 10 – Sunday 11 January, 2015Manchester Conference Centre

orthopods sharing important insights and clinical experience.

you will need to face – such as the understanding of fellowships – to make yourself stand out above the rest.

and of course, the BOA team. There will be limited spaces in 2015 so make sure you don’t miss out.

JOINT8

As Harold Macmillan once famously stated when asked what could steer a government most off course, he replied “events dear boy, events”. In the 21st century, David Cameron (another fellow Old Etonian) was heard to utter the modern day equivalent “shit happens”! My year as President of BOTA has certainly been eventful and if nothing else, the role of President is often to deal with issues and events that suddenly take place and to react as quickly and sensibly as possible in these circumstances. A very dedicated BOTA committee has supported me greatly and I would like to thank all of them for their hard work and dedication to their roles. In particular, I would like to thank Peter Smitham, my then Vice-President and David Machin, the Immediate Past-President, for all of their sage advice and words of wisdom. There is one more person without whom this job would have been well-nigh impossible. I am very lucky to have Rachael, who is such a supportive and understanding wife, who puts up with my constant meetings and absences, all without complaining (most of the time)!

This year has been incredibly busy for BOTA. As of this year, BOTA now has its own separate representation on the Joint Committee for the Intercollegiate Examinations (JCIE), the body responsible for overseeing the FRCS examinations for all ten surgical specialties, including the FRCS (Orth) examinations. We are the only specialty to have its own trainee representative with all the other nine specialties being represented by the Association of Surgeons in Training (ASiT). BOTA has been heavily involved with the National Selection process for ST3 numbers in T&O with four trainee representatives on the Selection Design

Group responsible for national selection. BOTA are strongly supportive of the principle of national selection and believe the process to be robust, fair and transparent.

BOTA were also involved with the Delphi exercise by the Centre for Workforce Intelligence (CfWI), commissioned by Health Education England (HEE) to review the workforce needs in the future for T&O up to 2030. The initial surprising conclusion from the CfWI was that there needed to be fewer training numbers with a suggested reduction from around 130 numbers to 60 over the next few years. There appeared to be flaws in the analysis with respect to the expected need and demand for T&O surgeons in the future and the final decision by HEE was that the new Local Education and Training Boards (LETBs), which have taken over from “deaneries”, would decide on the numbers needed based on local requirements. In the end, a decision was made to have 190 or so ST3 numbers for 2014 that meant that the competition ratio for this year was almost 2:1. The concern BOTA has with this is that the increase in ST3 numbers has to be matched by a corresponding increase in substantive consultant posts and that there has to be adequate provision made to ensure that trainees are trained in appropriate high quality training posts. What would be disastrous is if the expansion in training numbers was not matched by an expansion in consultant posts, leaving large numbers of post-CCT trainees without substantive jobs.

Probably the biggest issue to occupy the BOTA committee this year has been the impact of the Shape of Training (SHoT) review published in November 2013. The review sets out a number of recommendations on the future of medical training regarding the provision and configuration of postgraduate medical and surgical training for the next 3 decades, with the aim of “securing the future of excellent patient care”. The main focus of the review was to highlight the need for hospital doctors to provide more “generalist” care and to avoid becoming overtly specialist. In specialties such as general medicine, and to a lesser extent, general surgery, the trend towards “super-specialisation” has led to concerns that acute medical and surgical on-call was becoming increasingly difficult to cover and that trainees in certain specialties were unable to provide such emergency cover.

BOTA produced a position statement in response to the SHoT review in which both the positive and potentially negative implications of SHoT were highlighted. Certainly BOTA identified, there is much

about SHoT to support and recommendations such as a move back towards an apprenticeship model of training, longer placements and ensuring that only centres which demonstrate good training should have trainees, are to be welcomed. There are a number of recommendations, however, which are of significant concern. One of the recommendations in SHoT is to reduce the length of training in higher surgical training from 6 years to 4 years. After this period of training, the trainee would be awarded a Certificate of Specialist Training (CST) instead of a Certificate of Completion of Training (CCT). BOTA believes this will lead to the development of a less trained “consultant” with only general capabilities and is in effect, a sub-consultant grade.

The other concerning element of SHoT has been to introduce the concept of “credentialing”. This is where NHS trusts (i.e. employers) would be responsible for any further subspecialty training a “consultant” would need based on what the local population requires. This also assumes that the Chief Executive of an NHS trust (whose average career life expectancy is often measured in months rather than years) actually knows or is cognisant of what specialists are required in 5 years time by the local population. BOTA has concerns as to who would fund this extra training/credentialing and it is likely that the trainee would have to fund credentialing rather than the hospital trust. How would trainees decide which subspecialty to undertake credentialing in without having been exposed to that specialty beforehand? This concept also means that managers in NHS trusts would wield enormous influence over new consultants in that they may dictate what that consultant’s future subspecialty interest(s) might be and supports the creation of a “sub-consultant” grade who are capable of only providing a limited and general level of service without any subspecialty training. Although the authors of SHoT continue to stress that this would not be the case and that the term “consultant” would continue to exist, in practical terms, the consultant grade would be diminished, both in terms of the standard of training and its influence, and therefore much more malleable to any government.

President’s ReportJeya Palan

“The concern BOTA has with this is that the increase in ST3 numbers has to be matched by a corresponding increase in substantive consultant posts”

JOINT 9

It is BOTA’s belief that this proposition should be resisted as much as possible until a more definitive model of what this will look like is opened for debate.

The other “hot” topic for the committee has been the issue of training in Major Trauma Centres (MTCs). Professor Chris Moran is the National Clinical Director for Trauma in England and has proposed that all T&O trainees should rotate through a MTC for 6 months as part of their specialty registrar rotation. This has been debated at the Specialty Advisory Committee (SAC) for T&O at length and BOTA has been a key stakeholder and voice of this debate. It is very clear that the introduction of MTCs has made a significant difference in improving the likelihood of patients surviving major trauma. Initial results from the Trauma Audit and Research Network (TARN) suggest that 1 in 5 patients with severe multiple trauma injuries who would have died otherwise, are now surviving as a result of being treated in a MTC rather than a local district general hospital. However, BOTA had a number of concerns about making a MTC placement mandatory. The MTC model only exists in England and not in Wales, Scotland or Northern Ireland. The training in some MTCs has been very poor with one MTC on the verge of having its T&O trainees removed as a result. This is in part, due to working full shift rotas, combining elective and trauma work which means the elective component of the post suffers and also some Trusts having too many middle grades (required to fully staff a MTC middle grade rota, 24/7) which diminishes the operative experience gained in a MTC. This year, in order to gauge how trainees felt about the proposed MTC mandate, BOTA launched a national survey and 317 trainees (ST3 and higher) responded with representation from every region in the UK. Interestingly, trainees were very positive about working in a MTC

with 87% recommending working in a MTC. The positive aspects included having better exposure to complex trauma cases (pelvic and spinal injuries), better experience at managing complex trauma and an improved ability to work as part of a team. The negative aspects identified included getting decreased operative experience and the difficulty completing work-based assessments. BOTA has suggested that trauma and elective work are de-coupled when trainees work in a MTC so that the trainee only undertakes trauma and is able to concentrate on gaining their trauma experience. BOTA also recommends that where possible, full shift systems should be avoided. Whilst full shift rotas are in place in the majority of cases (59%), clearly other units are able to utilise a hybrid or partial on call rota and BOTA believes it is worth exploring how these units are able to do so.

The Education Weekend this year was hugely successful and my thanks go to Muzzy Rashid, Educational Representative and Sue Dale, the BOTA Events Manager, for devising such a fantastic educational content and social programme for BOTA members. BOTA are very grateful to our industry partners, as all of this is only possible because of the huge amount of support they provide. As some of you will know, I have a particular love of karaoke and one of my highlights of the weekend was singing New York New York with the band right at the end of the evening, although I suspect I may be in the minority on this one!

This year, BOTA also launched the British Orthopaedic Network Environment (BONE) website, the first national research and audit

collaborative network in T&O, designed by trainees to be trainee led and delivered. Jamie McConnell has been instrumental in working with the web developer to ensure that the BONE website functions well and has the support needed to ensure BONE is a success. BONE is now fully up and running with projects already posted ready for trainees and consultants to register and collaborate together. I hope you will visit the BONE website (www.bone.ac.uk) and register and start using it for all of your audit and research work. In the future, the other domains of BONE (Education, Clinical Leadership and Management) will hopefully be developed with projects in these fields. BONE is designed to help trainees fulfil their CCT requirements of 6 audits (including 2 completed audit cycles) and 2 peer-reviewed papers.

I would like to finish by saying it has been an incredible privilege and honour to serve as your BOTA President over the last 12 months and I hope BOTA has continued to go from strength to strength. The new BOTA President, Peter Smitham, will be excellent in his role and is forthright and insightful in his representation on behalf of trainees. The new BOTA committee is very strong with the right balance of experience and new blood, bringing to the table a wide range of skills and expertise. I wish Pete and all of the new BOTA committee the very best of luck. I am confident the future looks very bright for BOTA.

“Initial results from the Trauma Audit and Research Network (TARN) suggest that 1 in 5 patients with severe multiple trauma injuries who would have died otherwise, are now surviving as a result of being treated in a MTC”

JOINT10

One of the questions often asked is what does BOTA do, and this year as always has involved an enormous amount of work developing new ideas and concepts, improving established projects and fighting the trainees corner on the numerous meetings and organisations we represent orthopaedic trainees on. It has been an exciting year with a strong committee, which worked hard on all three elements and I have enjoyed working with everyone.

This year we have developed the new British Orthopaedic Research Network (www.bone.ac.uk) to enable national audits and research projects to be developed and launched; created new essay and research prizes; enhanced the TOTY award; significantly improved the educational weekend with workshops valuable to all stages of training including post FRCS workshops; been involved in the improvements being developed for the ISCP website; actively engaged in discussion about the radical changes being proposed to medical training, consultant contracts, simulation and rotations through major trauma centres. To do all this we need to constantly hear your views and be kept abreast regarding any local issues. It’s been fun and I would encourage everyone to become more involved in BOTA.

One of the key roles of the Vice-President is to organise the annual BOTA Trainer of the Year award and also coordinate the activities of the BOTA linkmen. In terms of meetings, as Vice-President my role consisted primarily of representing BOTA and the membership at the Joint Committee on Surgical Training (JCST) and also at the Intercollegiate Surgical Curriculum Programme (ISCP) meetings.

We held the second annual BOTA linkmen dinner in Manchester in January this year. The dinner is to thank all the linkmen for

their continued commitment over the year. This year we started with a small workshop and opportunity for the linkmen to voice regional concerns and suggest ideas on how to develop the linkmen role. This was a fantastic event with discussions going on through dinner at Bem Brasil, a Brazilian restaurant, and continuing on throughout the BOA educational weekend and into the Karaoke bars of Manchester. We will continue to develop this event and so all linkmen should put the weekend of the 10-11th January 2015 in their diaries.

The Shape of Training review has taken as considerable amount of debate and time this year. I am sure other reports are going to cover this in more detail and we will hear more about this as it evolves before the general election but I do suggest you glance at the website regarding this and how it is proposed to revolutionise medical training.

I am sure you are all aware of the increase in fees occurring and there has been a large amount of work on the new ISCP website. Please remember that trainee fees are now tax deductible.

Vice-President’s ReportPeter Smitham

Important changes to training 2013-2014:

• ARCP 1 required at ST6 level to apply to sit the FRCS exam. This is relevant to those trainees wishing to sit the November MCQs, particularly if your current ARCP date is after the closing date for registering for the part 1 FRCS MCQ exam.

• The research paper will be removed from the exam beginning in the November paper. The fifteen minutes reading time has been removed but the 12 questions will be replaced by statistics.

• PBA Level 4 is required in all primary (indicative) procedures for CCT. The SAC have re-worded PBA 4 so it does not require complications to have been dealt with, rather an understanding of how to deal with complications if they arise is required.

• SAC recommended 50/50 on WBA’s i.e. (50% PBA 50% CBD, CEX, DOPS etc). On the basis that clinical judgment, teaching and decision making is equally important as technical skill.

• Critical condition CBDs – there are 10 required for CCT at level 4!! These are not easily found on the ISCP website. Go to the curriculum page 128. BOTA have applied for these critical CBDs to be highlighted/accessible on ISCP.

The critical condition list is:

• Compartment syndrome (any site)

• Neurovascular injuries (any site)

• Cauda equina syndrome

• Immediate assessment, care and referral of spinal trauma

• Spinal infections

• Complications of inflammatory spinal conditions

• Metastatic spinal compression

• The painful spine in the child

• Physiological response to trauma

• The painful hip

• ISCP mapping – everyone should be colour coding their topics and syllabus at this stage to demonstrate progress and facilitate mapping of curriculum.

• E-logbook – Akin osteotomy has been added to first ray surgery thanks to BOTA i.e. scarf and akin two separate procedures.

• The T&O SAC will not accept PBA’s completed by non-consultant grade.

JOINT 11

Our accounts have seen another buoyant year. Your membership fees remain an important source of income to the association. The majority of our members are BOA Associate members: that is, trainees who hold full BOA membership. We have 773 such members, with the BOA contributing £40 per associate member, for a total of £30,920 in subscription fees. In addition, many trainees elect to join BOTA directly, rather than joining through the BOA. We now have 342 such members, up from 289 last year; they contribute a further £10,670 in membership fees. This increase may be a consequence of our new online application form, introduced last year, which means members can sign up in a matter of minutes rather than the many weeks required with our old paper-based process. Either way, we are grateful for your support. Another important source of income is web advertising, which has brought in £6,903 over the past year (versus £1,805 in the previous year). It may be a sign of the times that such advertising is increasing, or perhaps this is simply due to the salesmanship skills of our Web Editor.

The Committee have been busier than ever this year, attending a large number

of meetings around the UK in order to represent your views. Whilst such efforts carry great benefits to our membership, they can also incur greater financial costs: travel and accommodation expenses rose to £17,015.50 (versus £15,838.99 last year). We are ever-mindful of our responsibility to reduce outgoings wherever possible. Committee members are already encouraged to advance-book train tickets, we always advance-book hotel rooms, and we will continue to seek additional ways to control costs over the coming year.

Our largest outgoing is the annual Educational Weekend, which is made possible due to the generous support of industry sponsors. This year our sponsorship totalled an incredible £54,250 (versus £38,250 in the year ending June 2013). This is the highest level of sponsorship that we have ever attracted by a considerable margin, and we are very grateful for the ongoing support of our sponsors: Acumed, AOUK, Arthrex, Ceramtec, Stryker, X-Bolt, Zimmer. Particular

thanks are due to our Platinum-level sponsors, who invested additional time and money to increase their level of participation in the event: Heraeus, Orthofix, Hodgson Solutions, and our first-ever Diamond-level sponsor, DePuy Synthes, who ran a series of additional workshops which were very well received by delegates.

As ever, this industry support allows us to heavily subsidise the cost of the event. Ticket sales brought in a respectable £19,728.60 net of payment processing fees, but simply hiring the venue and paying for educational activities cost us £71,628. Rooms, equipment hire, staffing, printing…the list is long. This figure does not include the social activities such as a black tie dinner, live band, golf tournament, go-karting, duck herding, etc. These ‘extras’, which are a real highlight for

many attendees, cost BOTA a further £13,738. This component of the weekend is accounted for in the delegate and partner attendance fee; it is not covered by sponsorship, and to my knowledge never has been. Thus it can be seen that without industry sponsorship we would have to charge £672 to each of the delegates, rather than our rather more reasonable figure of £250 per delegate. This rather simplified illustration disregards the day delegates and partners who attended at an even lower rate, of course, but the point still stands: if you have never been to a BOTA Educational Weekend you are really missing out on a terrific deal.

We have spent £6,380 in design and development fees to launch the BONE project, which is described in detail elsewhere in these pages. The committee are excited about the potential of this site, which is intended to promote and facilitate collaborative research within the UK orthopaedic community. We believe that it will prove to be a worthwhile investment.

Other smaller outgoings include three medical student bursaries of £500 each, and we are proud to continue supporting the BOTA/Heraeus Kenya fellowship which sponsors two trainees at £750 each. We also pay for a stand at the BOA Annual Congress, and make a contribution of €1 per member to the Federation of Orthopaedic Trainees in Europe (FORTE). Finally, we have made a charitable donation of £1,000.

The full accounts are reported semiannually to all members who attend either our AGM, or the EGM at the BOA Instructional Course in January. We look forward to seeing you at both.

Treasurer’s ReportJamie McConnell

“Our largest outgoing is the annual Educational Weekend, which is made possible due to the generous support of industry sponsors”

JOINT12

When I took up the position of BOTA SAC Representative in June 2013, I had no idea the year I had in store and what we as a committee would achieve on behalf of trainees throughout the United Kingdom. Firstly it has been an honour and a truly humbling experience. Taking over and following on from Fraser Dean (SAC Rep 2012/13) has been no easy task. In addition to my official positions, I also at times made representations to the ISCP and Training Standards Committees.

Specialty Advisory Committees

This year the SAC has been truly busy. My duties kicked off at the TPD forum within minutes of being elected. In this meeting trainees raised the issue of the difficulty attaining Indicative Numbers in first ray surgery amongst others. The SAC highlighted that these numbers were indeed indicative and were intended to reflect the quality of training and should not be used in a punitive manner. First ray surgery remains under review, as do all the other indicative numbers. At the final SAC meeting of my term the SAC Chairman gave an undertaking to where possible make any future changes to indicative numbers applicable to ST3 trainees only, to avoid the perception of “shifting goal posts” that current trainees have.

The introduction of the 2013 T&O Curriculum took up a large proportion of BOTA’s time in the early part of our term of office. The new curriculum took effect from 01/08/13 and applies to all trainees who will obtain CCT from October 2014 and beyond. There have been several discrepancies in the new curriculum and these have been highlighted to the SAC and the Training Standards Committee of the BOA, which is responsible

for curriculum design. While some of these inconsistencies have been addressed, others such as mandatory PBA’s, some of which do not currently exist, will take longer to work out and SAC Representatives may need to take a pragmatic role when assessing CCT applications.

Unfortunately BOTA lost the argument on pre-CCT fellowships due to unanimous requests from TPD’s for the SAC to back post-CCT fellowships. In December 2013 the SAC took this decision and has now recommended that all fellowships (with the exception of hand interface fellowships) be post-CCT. A pragmatic approach has been taken for fellowship arrangements that were already in place prior to this decision.

The SAC have also with BOTA’s support approved the introduction of ST4, ST6, and penultimate year ARCP way-point assessments. These forms will eventually be available on ISCP but in the interim trainees will be required to complete these documents and bring to the relevant ARCP. The way-point assessments will allow the ARCP panel to get an idea of the trajectory of training for that individual trainee compared to the JCST CCT guidelines, and make appropriate recommendations to address deficiencies early.

The hot topic of making placements at Major Trauma Centres (MTCs) mandatory for all trainees was the final focus of the year. While MTCs since their introduction have undoubtedly improved patient care, the quality of training across the various MTCs is not uniform. BOTA also highlighted that several deaneries/LETB’s do not have MTCs and this mandatory imposition would put trainees in these regions at a disadvantage. It has been agreed that at this point in time MTC placements cannot be made mandatory, however, where possible trainees should be allowed to undertake such placements. Quality of training in MTCs and the impact on elective training will remain under review.

Intercollegiate Specialty Board (ISB) for Trauma & Orthopaedics

I enjoyed my time representing trainees at the ISB for Trauma & Orthopaedics. Over the year several changes have been made to the FRCS examination that trainees should

be aware of. Firstly, new FRCS reference forms now stipulate trainees must have an ARCP 1 at ST6 in order to be eligible for the examination. This means that the exam can now only be taken at ST7 or ST8.

The second major change to the exam will take place from November 2014 onwards where the research paper will be dropped from the Part 1 exam and will be replaced with 12 questions on statistics and research methodology. This means that the 15 minutes for reading time will be removed from the exam, however the number of questions, and the time for answering questions will remain unchanged.

As part of my role in February 2014 I took part in the Part 1 standard setting exercise. I found this to be a useful exercise that allowed me to understand the lengths to which the ISB go to ensure that the Part 1 exam is fair.

Joint Committee on Intercollegiate Examinations (JCIE)

For the first time BOTA was granted permission to represent Orthopaedic Trainees on the Joint Committee on Intercollegiate Examinations. This committee sits several times a year and governs the format, structure, execution, and quality assurance of the FRCS examinations for all surgical specialties. Many of the recent and future changes to the T&O FRCS examination have been made at the JCIE level and it is a privilege for BOTA to be allowed input at this level on behalf of our trainees.

National Selection

While not a formal part of my role, I was invited to be a member of the Selection Design Group for the Trauma & Orthopaedics 2014 ST3 National Selection process. The BOTA president and I, along with our predecessors took part in the process of Selection Design over a series of lengthy meetings. The focus of the group was to learn lessons from the 2013 process, ensure the system measured all qualities of a good trainee so the best trainees could be selected, and ultimately to ensure that the process was fair. I personally took part in station design, and was station lead for the Communication Skills station for the week of interviews. Overall I believe the process to be rigorous and fair. There are no doubt lessons to be learned from the 2014 exercise, however, most interviewers noted an improvement over the 2013 process. There has been great debate since results were announced about the decision to make the clinical knowledge station a pass/fail station. While BOTA was not a part of this decision, we have highlighted the concerns of junior members who were

Specialty Advisory Committees (SAC) RepresentativeNicholas Ferran

“I had no idea the year I had in store and what we as a committee would achieve on behalf of trainees throughout the United Kingdom”

JOINT 13

I followed on from Nicholas Ferran (this years SAC rep) in June 2013. It has been a pleasure to represent BOTA as a member of the BMA Multi-Specialty Working Group (MSWG), and to act as observer on the BMA Junior Doctors Committee (JDC) and Central Consultants’ & Specialists Committee Orthopaedic Sub-Committee.

This year the JDC has remained focused on the junior doctors contracts. The JDC

continues to engage with the Department of Health representing the needs of all trainees including those in less than full time training, maternity leave and academic trainees to name but a few. This has been a very difficult process so far with an initial deadline of August 2014 it is likely to continue well into my next term as BOTA BMA rep. Although BOTA observes on the Junior Doctors Committee I would encourage more orthopaedic trainees to stand for election to the committee at the annual junior doctors conference. So please get involved.

As a member of the MSWG I have continued to raise concerns regarding the Inter Deanery Transfer (IDT) process. Significant improvements have been made to the process, with greater satisfaction than ever before. BOTA have ongoing concerns with regard to deaneries opening up posts to IDT eligible trainees throughout the country.

The MSWG and JDC have been heavily involved in responding to the Shape of Training review Led by Professor David Greenaway and published in October 2013. BOTA responded to the report with praise and concerns over a number of the reports findings and recommendations. BOTA has focused on the needs of orthopaedic trainees and issues that might affect undergraduate and postgraduate orthopaedic trainees of the

future. As a result of the BOTA response to the Shape of Training report, orthopaedics has been acknowledged as a specialty that does provide excellent general training within trauma alongside a specialist elective interest. BOTA will continue to engage with the four-country Medical Education Scrutiny Group involved with producing a report for government.

I am continuing as BMA rep for another year and will carry on the fight to improve trainee conditions and resist change that will negatively affect the needs of all BOTA members. I would also like to stress again that BOTA needs the voice of its members to engage with the BMA in order that we are involved in the decisions that may determine our future as trainees and consultants…

British Medical Association (BMA) RepresentativeMarshall Sangster

left disgruntled by this decision. While this decision on the application of scores is contentious it should not detract from the overall process or the principle of national selection which is fair.

The year representing you has been both challenging and rewarding. I represented you to my best ability, I hope that I made a positive impact on your behalf, and I thank you all for the opportunity. I would like to wish the new Committee, and in particular my successor Jerome Davidson, a successful and productive year.

“Orthopaedics has been acknowledged as a specialty that does provide excellent general training within trauma alongside a specialist elective interest”

JOINT14

My name is James Shelton, I am the outgoing Junior BOTA representative and would like to take this opportunity to share with you what the BOTA committee has been doing for its junior members this year. I graduated from the University of Dundee in 2010 and am currently a core surgical trainee in North West Deanery (Mersey Sector) themed in trauma & orthopaedics. I have been a BOTA member since FY1 and shall continue to serve on the committee as honorary secretary next year.

I have had a number of roles and responsibilities during this year including a seat on the joint committee on surgical training core surgical training committee (JCST CSTC) and most importantly have been through selection for ST3 in trauma & orthopaedics.

I was elected to the role of Junior Representative on the premise that I wanted to give an accurate representation of the challenges junior surgical trainees face when trying to achieve their training goals. Both BOTA and ASIT have a seat on the JCST CSTC however I was the only representative who was a core trainee or who had been through a core training program. With this in mind I have been able to express the challenges facing core trainees such as the scrabble to do your MRCS as soon as possible, competing with foundation doctors and locum appointment for service doctors for theatre and clinic time and with this in mind the falling numbers of applicants for core surgical training positions. I believe I have made good progress on this topic both pushing for and being appointed to a quality assurance sub-committee of the CSTC. I hope my successor will welcome the challenge of making these political gains mean better training on the ground for our members.

National Selection for ST3 is still in its infancy however I firmly believe it has lead to a fair and reliable recruitment process. The five stations – Portfolio, Technical, Communication, Clinical/Anatomy and Presentation & List Planning represented a wide breath of areas in which to display your

knowledge and a mixture of two examiners along with technical and lay observers ensured reliability amongst the stations. As a candidate it is one of the most nerve wracking experiences I have been through and felt much more like an exam than an interview but in retrospect nothing was asked of me that I would not come across in clinical practice and with proper preparation and a good, truthful portfolio it is achievable. This year is one of the first to see national training numbers unfilled which adds validity to the process.

Lastly I would like to introduce my successor Will Nabulyato who shall take over my roles and responsibilities on the committee. I wish him the best of luck building on the ground work that my predecessors and I have established.

Junior ReportJames Shelton

“As a candidate it is one of the most nerve wracking experiences I have been through and felt much more like an exam than an interview”

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I had some pretty big boots to fill this year taking over as the academic representative from BOTA’s new president Peter Smitham. Taking on the role meant I was fortunate to represent BOTA and its members on a number of committees including the BOA research committee, Arthritis Research UK (ARUK) clinical study group for trauma and orthopaedics, the Royal Society of Medicine (RSM) Orthopaedic section, the British Orthopaedic Research Society (BORS) committee and the British Society for Surgery of the Hand (BSSH). The year has been a real eye opener for me and it has been a privilege to sit on so many committees that shape the research agenda for orthopaedics in the UK.

A number of important changes have taken place this year. The ARUK clinical study group in Trauma and Orthopaedics, which was chaired by Damian Griffin, has now been disbanded and there are plans to change its focus to disease specific groups so watch this

space to see how orthopaedics will now be supported by ARUK moving forward. There have also been important changes at the BOA. The BOA research committee is currently chaired by Amar Rangan and this year it was decided that a change in strategy was needed. This has led to the committee appointing a specialist research methodologist based at the York clinical trials unit. This replaces the previous system of small pump priming research grants with the methodologist’s remit to help the BOA set-up clinical trials matched to current clinical priority areas.

The RSM orthopaedic section has had an excellent year under the stewardship of Fares Haddad. The section ran a number of exciting educational events including the president’s prize papers, which was won by BOTA’s very own Mustafa Rashid. Next year will see Tim Briggs take over the reigns and so I am sure the section will continue to grow.

I must thank my colleagues Peter Smitham and Jeya Palan who attended BSSH council meetings on my behalf this year. I was however privileged to attend the planning day for June’s instalment of the BSSH’s instructional course. This was a marathon of a meeting in which the program for June’s meeting was reviewed and planning for the next two instalments of the course took place. As well as this we discussed BOTA’s role within the society. It was felt that the best way for BOTA to interact with the BSSH was for a BOTA member to attend the two annual BSSH committee meetings as well as the two annual course-planning meetings before each instalment of the instructional course. This person would ideally also attend some BOTA committee meetings and ensure the continued collaboration between the two societies. I am delighted to announce that Alex Hazzlerigg the outgoing BOTA secretary will now fill this role.

My final meeting as BOTA academic representative was a bit of a slog–I drove to the BORS committee meeting in Bath on the Sunday after the AGM on route back to Newcastle. The 8 hour 500 mile round trip was however not in vain and we had a very productive meeting following which we will see important changes to the BOTA BORS prize. Moving forward this prestigious award will now likely be held at the BORS meeting itself. This will be a huge step forward in terms of promoting the kind of interaction that is key to translational collaborations and hopefully really bring the two societies together.

Another exciting development this year has been the British Orthopaedic Networking Environment (BONE). It is aimed at facilitating collaborative research and audit for orthopaedic trainees of all grades. The website for BONE is now live at bone.ac.uk and I would urge anyone interested in getting a national collaboration moving to register and get involved. If the general surgeons can so can we!

Finally I would like to thank everyone who engaged with the various prizes we ran this year–Medical student elective bursary, BOTA BORS prize, BOTA ORUK poster and podium prizes and the Cambridge Orthopaedic Writing prize.

Academic ReportRamsey Refaie

“The year has been a real eye opener for me and it has been a privilege to sit on so many committees that shape the research agenda for orthopaedics in the UK”

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This has been my second year on the BOTA committee as Scottish representative. It has been with great pride that I have represented UK trainees and Scottish trainees in particular. It never ceases to amaze me the important voice BOTA has on the committees that run orthopaedic training and orthopaedics in general, including the SAC, JCST, Royal Colleges, JCIE and BOA to name but a few. From a Scottish perspective I have

thoroughly enjoyed sitting on the Scottish Committee for Orthopaedics and Trauma (SCOT), the Scottish Academy of Trainee Doctors Group, the RCSEd T&O SubSpecialty Group and RCPSG Trainee Committee. More latterly I sat on the JCST, JCIE and ISB committees and again, the importance these committees confer on the trainee representative cannot be overstated.

What a year it is in Scotland. With the Commonwealth Games, the Ryder Cup, the 700th anniversary of Bannockburn and the wee matter of a referendum in September one could be forgiven for forgetting about the big issues affecting orthopaedic trainees

north of the border. Many things are in flux, the issue of run-through vs ST3 recruitment is evolving and the formation of trauma centres in Scotland for example. These plus issues affecting the whole of the UK such as the junior doctor contract, EWTD and Shape of Training mean that there is a certain degree of uncertainty about the future. Add to this the referendum and it will be fascinating to see how it all pans out. It is incredible to

think that this may be the last Scottish Rep report before the process of independence starts… Needless to say the BOTA committee and regional linkmen are doing and will do everything we can to ensure the most positive outcome possible for orthopaedic trainees regardless of what transpires.

I would like to thank the regional linkmen for all their help in the past year; Iain McGraw (West of Scotland), Chris Munro (North East of Scotland), Mike Reidy (East of Scotland) and Eleanor Davidson (South East of Scotland). Iain and Ellie have passed on their responsibilities to Findlay Welsh and Vittoria Bucknall and I wish them all the best in their

new roles. Mike Reidy is taking over from myself as Scotland Representative and I have no doubt he will do a fantastic job.

Finally I would like to thank all of last year’s committee for what has been a thoroughly productive and enjoyable year. It has been a pleasure getting to know and working with all of you.

Scottish Representative ReportGerry Cousins

Greetings from Belfast! What a busy year it has been!! Let me begin by congratulating Mr Connor Mullan, Mr Andrew James, Mr Niall Breen, Mr Owen Diamond and Mr Sean McKenna on passing the FRCS (orth) exam and continuing the 100% pass rate for yet another year from Northern Ireland.

Congratulations to Mr Owen Diamond on winning the coveted MAC arthroplasty prize trip to Vail Colorado.

Congratulations to Mr Rakesh Dhokia, winner of the free paper session at Britspine 2014.

Congratulations to Miss Catherine Gilliland, winner of the Martin Medal Prize 2014.

I would also like to congratulate Miss Elaine Robinson, Mr Tim Doyle and Mr Maurice O’Flaherty on their Consultant appointments.

This year has seen the stepping down of our TPD, Mr McAlinden, who has been appointed Clinical Director of Musgrave Park Hospital. He has been a fantastic programme director and on behalf of all the trainees we wish him well in his new position. His successor, Mr Mockford, is a local arthroplasty surgeon who is passionate about teaching and education and we look forward to training under his new direction.

Last and certainly not least we have the Trainer of the year award. For the second year running, Mr Niall Eames has been voted by the Belfast trainees as their most influential and inspirational trainer. We hope that this award will stimulate and encourage excellence among trainers in Northern Ireland.

Northern Ireland Representative ReportCiara Stevenson

“It never ceases to amaze me the important voice BOTA has on the committees that run orthopaedic training and orthopaedics in general”

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It has been an eventful year in Wales, I am glad to report that BOTA is growing in strength in Wales. With the help of the RCSEd, Wales deanery and WelshBone, we successfully held the first South Wales Orthopaedic and Trauma Showcase (SWOTs) in June 2014 at the University Hospital of Wales, Cardiff. I would like to say a big thank you to the faculty, especially to Mrs Judith Murray, Mr Paul Roberts, Mr Angus Robertson, Ms Clare Carpenter and Mr Manav Raghuvanshi for their inspirational lectures. SWOTs has truly showcased the excellent quality of clinical and academic training in the Wales orthopaedic training programme. In my opinion Wales is the best training programme in the UK and it is something that we should be proud of. Patient focused high quality training has always been the underlining principle of BOTA and I am so glad that we were able to demonstrate that in SWOTs.

While we are on the topic of quality of training, I would like to report that there have been many nominations for the Wales Trainer of The Year award. The final nominees were Ms Clare Carpenter, Mr Mark Holt and Mr Dave Woodnutt. With the help of our online voting system this year, more trainees were able to take part in the voting process. With the majority of votes, Ms Clare Carpenter has won the Trainer of the year award 2014. This is the first time that TTY was won by a newly appointed consultant and I would like to express my congratulations to her. Ms Carpenter is always enthusiastic, approachable, committed to teaching and engages us with fantastic interactive learning opportunities. She is an inspiration to all Welsh trainees and beyond.

In terms of research and academic aspects of training in Wales, I am glad to report that 80% of our current trainees have already done or are working toward a Masters or Doctorate degree. With the newly established Wales Orthopaedic Journal, Wales orthopaedic research has entered a new era. The quality of research in Wales has been reflected in the Welsh Orthopaedic Society meeting in Carmarthen, with the guidance of Mr Tim James and Mr Neil Price. The research presented in the meeting was excellent with high clinical impact and I am sure it will translate into better patient care.

Besides its academic excellence, Wales also offers great clinical and practical experience for trainees. Although there have been political issues with elective theatre cancellations in the winter months in some trusts in Wales, owing to effective planning and allocation between trainers and trainees, the impact on training has been minimal.

As you can see, Welsh trainees and trainers have been working together to facilitate

excellent academic and clinical training. However, there has also been some unfortunate events affecting training this year. The Postgraduate Dean has confirmed following the advice from the SAC in Trauma and Orthopaedics, all Fellowship experience has to be post CCT, no applications for OOPE prior to CCT will be accepted (except for the National Hand Fellowship). BOTA has issued a statement with regards to this national move of banning pre CCT fellowship. In my own opinion, I feel that banning pre CCT fellowship would put type 1 trainees at a disadvantage in the national and international market, therefore it is a set back for training. I understand that our TPD has worked very hard to communicate this inevitable decision to trainees and we are all very grateful for his input.

Looking forwards, I would like to say thank you once again for electing me as the Wales representative, it has been a wonderful year, with your support we can build on this year’s success and further improve training. Mr Vishal Paringe will be your next BOTA Wales Representative; with the help of our linkman Mr Naz Modieen I am sure they will continue to help welsh trainees to engage with BOTA.

Finally, I would like to present this photo of the Wales Orthopaedic Trainee, “Class 2014”, taken on the registrar day in Cardiff 2014 to demonstrate the strength and happiness of our training programme.

Welsh Representative ReportPaul Lee

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SecretaryName: James Shelton

Deanery: Mersey

Year of Training: ST3

Greatest Strength: Determination.

Greatest Weakness: Not knowing when to keep my mouth shut!

Interests: Professionally my interests are presently focused around trauma especially transferable skills to developing nations such as Malawi where I have visited a number of times with the Feet First team. Personally I enjoy a range of exciting but infrequent sporting activities such as snowboarding, scuba diving and high altitude mountaineering. Music is my other great love, drumming for a number of bands whilst at university, I still enjoy playing socially to date.

Immediate Past PresidentName: Jeya Palan

Deanery: East Midlands Leicester

Year of Training: ST6 (though it feels like I have been a trainee forever…)

Greatest Strength: Getting on with people; passionate about what I do; my wife!

Greatest Weakness: A penchant for karaoke and an inability to carry a tune. Cannot play golf!

Interests: Food and drink, golf, walking holidays with the pooch, football, tennis.

PresidentName: Peter Smitham

Deanery: North East Thames (Stanmore Rotation)


Greatest Strength: Investigative mind.

Greatest Weakness: Unable to stay with the in-laws due to animal allergies (or maybe that’s a strength!).

Interests: Sailing, scuba diving and seeking new adventures.

Vice PresidentName: Mustafa Rashid

Deanery: London NE Thames (Percivall Pott)


Greatest Strength: I am incredibly committed and passionate about orthopaedics and especially representing trainees locally, regionally and nationally. This attribute has allowed me to develop as a trainee in several aspects and I am truly honoured to have been elected as a BOTA committee member.

Greatest Weakness: I am probably too critical of my own work at times.

Interests: I love spending time with my wonderful girlfriend (I hope she reads this), playing golf, travelling, playing tennis, skiing, and meeting up with friends regularly.

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EducationName: Simon Fleming



Greatest Strength: Not afraid to take on new challenges and get the job done!

Greatest Weakness: Need to learn when to shut up!!

Interests: Food, books, rugby and movies.

TreasurerName: Steve Kahane



Greatest Strength: Organisational skills.

Greatest Weakness: Overestimating my organisational skills leading to me taking too much on!

Interests: I have a keen interest in education. I help run an Orthopaedic Interview Course for ST3 applicants and have talked at the RCS and RSM regarding getting an ST3 post-Happy to help any keen juniors out there.

SAC RepresentativeName: Jerome Davidson

Deanery: London Deanery


Greatest Strength: Perseverance.

Greatest Weakness: Managing my credit card.

Interests: All the regular sports (cricket, tennis, hockey), reversing my cardiovascular risk factors, and trying to remember there is a world outside of orthopaedics.

PublicityName: Sara Dorman

Deanery: Mersey


Greatness Strength: Motivated and determined.

Greatest weakness: Impatient, athletically challenged.

Interests: Work related interests include paediatrics and general trauma. Personally I love to travel, enjoy plenty of good food and drink, avid supporter of the six nations rugby, enjoy adventure sports (which require no actual skill) including bungee jumping, skydiving and I have recently completed a 300km husky sledding challenge in artic circle to raise money for Feet First.

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BMA RepresentativeName: Marshall Sangster

Deanery: Severn


Greatest Strength: Approachability.

Greatest Weakness: I get frustrated with people who do not take pride in their work and do not perform to the best of their ability.

Interests: At work lower limb arthroplasty and trauma. However, out of work I like to play golf, mountain bike and spend time with my friends and family.

AcademicName: Payam Tarassoli

Deanery: Severn


Greatest Strength: Encyclopaedic knowledge of takeaways in the vicinity of whatever trust I happen to be working at.

Greatest Weakness: I have two. My unwavering support for Arsenal FC, and the 50% NHS discount at Dominos Pizza (see strengths).

Interests: Watching YouTube clips and engaging in lively discussion with other users in the comments sections, 5-a-side footy, robots, occasional research.

Web EditorName: Daniel Ryan

Deanery: Severn


Greatest Strength: Teamworking.

Greatest Weakness: Steak.

Interests: Food, squash, tennis, medical education, shooting (not in that order).

BONE Project CoordinatorName: Jamie McConnell

Deanery: London (RNOH)


Greatest Strength: Ability to focus on one thing to the exclusion of everything else.

Greatest Weakness: Selective inability to focus on one thing to the exclusion of everything else.

Interests: Totally devoted father, movie buff (currently into 70s sci-fi), and aficionado of music that other people seem to find unlistenable. Orthopaedically speaking, lower limb arthroplasty.

Northern Ireland RepresentativeName: Ciara Stevenson

Deanery: Northern Ireland


Greatest Strength: Enthusiastic and driven.

Greatest Weakness: Strange accent…have been known to sound like Nadine Coyle from Girls Aloud on occasion…and for that I apologise!

Interests: Work related: Arthroplasty, soft tissue knee reconstruction, arthroscopy and spines…a healthy mix! Not forgetting BOTA!! Playing the piano, music festivals, Liverpool FC, super cars (track/rally driving) and Christian Laboutin shoes.

Scottish RepresentativeName: Mike Reidy

Deanery: East of Scotland


Greatest Strength: Honest and enthusiastic.

Greatest Weakness: Golf.

Interests: Golf…football and family

Wales RepresentativeName: Vishal Paringe

Deanery: Wales


Greatest Strength: I would consider myself as a very enthusiastic team player with an ability understand the potential amongst my colleagues and harness it to its optimum.

Greatest Weakness: I am definitely going to vote in for a stuffed fish.

Interests: At the risk of sounding very boring, I would say watching a 5-day cricket test while cooking an authentic stuffed crab curry. Travelling and vintage car model collecting have been recent additions to my list of interests.

Junior RepresentativeName: William Nabulyato

Deanery: Eastern Deanery

Year of Training: CST 2

Greatest Strength: Endurance and enthusiasm.

Greatest Weakness: Flirtatious liaisons with deadlines.

Interests: Professionally all about trauma with a penchant for upper limb. I have a keen interest in education, particularly undergraduate and immediate postgraduate teaching in T&O as this is often poorly taught (if at all) and is something I’m really passionate about. Enjoy a game of basketball and football and have been sighted plummeting down ski slopes but nothing beats a cheeky game of COD/FIFA with a spot of ‘upstanding’ night time socialising. Oh, and spending time with my girlfriend!

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Linkmen Reports

Linkmen Regional Reports 24-33

World Orthopaedic Concern (WOC) 34

Humanitarian ‘Out of Programme Experience’ 35

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Armed ForcesMajor Hugo Guthrie

In a year that has seen continued insurgency in Afghanistan, renewed chaos in Iraq, misery in Syria and instability in the Ukraine it is perhaps a surprise that the Royal Navy and Royal Air Force are reducing the number of trainees and consultants on their strength. I hope that this unexpected and unwelcome event will bring unforeseen opportunities in civilian life for those concerned and that the armed forces do not soon regret losing so many high quality surgeons. The process of transferring NTNs to civilian deaneries is underway and I hope that the trainees affected will be able to continue their T&O training without further disadvantage.

Having successfully benchmarked at national selection Major Sushmith Ramakrishna was awarded the single Army NTN for 2014 and will train in Wessex. Majors Jeremy Granville-Chapman, Dafydd Edwards and Neil Walker, Surg Lt Cdrs Tim Bonner and Sandy Wood and Sqn Ldr Ed Spurier have all successfully negotiated the FRCS (Tr&Orth) – congratulations to them all.

Major Edwards has now started working towards an MD at the Royal British Legion Centre for Blast Studies at Imperial College. Sqn Ldr Paul Hindle continues his PhD in Edinburgh and has recently secured further research grants from Joint Action and the Edinburgh Musculoskeletal Research and Education Endowment Fund. Major Will Eardley has submitted his MD thesis to Newcastle University and awaits the opportunity to defend his work.

Major Granville-Chapman was awarded the Sir Walter Mercer Gold Medal for his performance in the FRCS(Tr&Orth) examination last year and becomes the BOA young ambassador. Major James Singleton was awarded the Montefiore memorial prize for being the surgical trainee who has most distinguished himself across the whole Royal Army Medical Corps for his research into blast injury and traumatic amputation. Surg Lt Cdr Jowan Penn-Barwell was awarded the Headley Court Trustees prize for his paper on outcome after unilateral amputation. Defence trainees have been awarded two prestigious fellowships; the Watanabe Travelling Shoulder Fellowship to Surg Lt Cdr Paul Guyver and the BOA Ram Kumar Chatterjee Travelling Fellowship to Sqn Ldr Neal Jacobs.

At the Combined Services Orthopaedic Society meeting held at RAF Wittering Sqn Ldr Spurier won the Philip Fulford memorial prize for best overall presentation, Major Singleton the Peter Templeton memorial prize for best presentation by a trainee and Sqn Ldr Hindle the prize for best clinical paper. Additionally Major Eardley was awarded a CSOS travelling fellowship in support of his visit to Shock Trauma in Baltimore.

Surg Lt Cdr Guyver starts as a Consultant at Derriford Hospital, Plymouth in the autumn while Major Eardley has also gained his CCT. Lt Col Philip Rosell and Wing Cdrs Irwin Lasrado, David Stitson and Sean Masterson are all leaving the armed forces but all are likely to continue in their current trusts as civilian surgeons.

Through sponsored sports events and donating honorariums for extra-curricular activities Defence Trauma and Orthopaedic trainees have supported The Soldiers Charity, Find a Better Way, Toe in the Water, Combat stress and various local charities. Less conventionally Major Edwards came 2nd at the Army Skeleton championships and Sdn Ldr Spurier was awarded the livery of the Honourable Company of Air Pilots. Finally many congratulations to Major Zine Beech whose daughter Rowena was born on 5th November 2013.

London South East ThamesLucy Cooper

This has been a successful year for the majority of South East Thames trainees sitting the FRCS exam. Congratulations to you all!

There have been several new consultant appointments in our region and several of our trainees have successfully secured consultant posts in other regions too… Well done!

Congratulations to our new programme director Ms Back on achieving SE Thames Trainer of the Year.

Within South East Thames, the earliest opportunity we now have to partake in the FRCS exam is ST7. We continue in London to submit the compulsory 80 WBAs per year. Fellowships will now be arranged after success in achieving CCT.

Our Trauma and Orthopaedic MSc continues with our former programme director, Mr John Shepperd leading at the helm. Good luck to all those awaiting results of the most recent summer exams.

London South West ThamesJohnathan Craik

It has been another good year in South West Thames with many of our senior trainees successful in achieving the FRCS (orth). Well done to Nik Briffa, Gavin Brigstocke, Alex Dineen, Sabahat Gurdezi, Josh Jacobs, Carl Jones, Ibrahim Roushdi, Oliver Templeton-Ward and Jamie Young. In particular a huge congratulations to Mr Jeremy Granville-Chapman who was awarded the gold medal!

On behalf of those now FRCS positive a big thank you to all the regional trainers. The high quality of training across the region has been reflected in our trainer of the year award nomination process. We saw a huge number of consultants being put forward but alas there could be only one winner – or in the case of South West Thames two! One for South London and one for Kent Surrey and Sussex. Congratulations to Mr Najab Ellahee from Epsom and St Helier University Hospitals, and Mr Ben Rogers from Brighton and Sussex University Hospitals. Their encouragement and support for trainees in developing both their clinical and academic skills is greatly appreciated and they are very worthy winners of this award.

The South West Thames deanery division between South London and Kent Surrey and Sussex is now well established with trainees allocated to rotations within each of the regions. Thank you to Mr Dominic Nielsen (TPD for South London) and Mr Matt Solan (TPD for KSS) for their hard work in delivering a fantastic training programme. Your dedication and guidance is greatly appreciated.

Despite separate training rotations we do still enjoy a shared teaching programme across SWT, together with two annual research meetings. Thank you to Mr Nielsen for organising the Raine Prize meeting at St Georges Hospital. Thank you also to Mr Phil Mitchell and the team at St Georges for putting together a fantastic day at the Roehampton Club for the annual Sam Simmonds meeting. Both were a resounding success and well done to the prize winners.

Raine Prize 6th Dec 2013

Sam Simmonds Prize 16th May 2014

1st Mr Jonathan Quayle Mr Joideep Phadnis

2nd Mr Asim Khan Mr Johnathan Craik

3rd Mr Dan Wilson Mr Will Kieffer

Linkmen Regional Reports

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Congratulations also to Mr Alex Trompeter for winning a BOA travelling fellowship and to Mr Chris Gee who won the BOTA/FORTE best presentation prize at EFORT for his paper ‘Patient reported outcomes in very elderly active patients with distal radius fractures treated with volar locking plates.’

Finally we welcome the following newly appointed regional consultants – apologies if I have missed anyone out! Mr Alex Trompeter to St Georges Hospital, Ms Kate Gill and Mr Olusegun Aiyenuro to Royal Surrey County Hospital, Mr Ian Gill and Mr Nashat Siddiqui to Kingston Hospital, Mr Rishi Chana to Ashford and St Peters Hospitals, Ms Rebecca Owens to Frimley Park Hospital and Mr Philip Wraighte and Mr Madhu Rao to Chichester and Worthing Hospitals. In addition we say thank you and farewell to Mr Peter Magnussen from Royal Surrey County Hospital, Mr David Dempster from Frimley Park Hospital and Mr Martin Bircher from St Georges Hospital who are retiring this year.

London North West ThamesAmarjit Anand

It has been another successful year for trainees on the Northwest Thames London rotation. The past year has seen a number of former trainees successfully appointed into substantive consultant posts. These include Bobby Anand (Croydon University Hospital, Knees), Oliver Stokes (Exeter, Spine), Ajay Gupta (Northwick Park, Lower limb), Jas Daurka (Imperial College Hospitals, Pelvis & Hips), Reza Jenabzadeh (Hinchinbrook, Lower Limb), Apu Bhalla (North Middlesex, Hands) and Simon Ball (Homerton, Shoulder & Knees).

We would like to congratulate Simon Newman, Nirav Patel, Vivek Gulati, Joseph Windley, Khaled Sarraf, Jamie Mckenzie and Cenk Oguz, who have all successfully passed the FRCS(Orth) exam this year.

The regional teaching programme has continued to go from strength to strength under the guidance of Khaled Sarraf and Programme Director Mr Chinmay Gupte, who have made significant efforts in organising excellent FRCS(Orth) focussed sessions. The monthly regional Orthopaedic World Literature Society (OWLS) Journal Club continues to expand under newly appointed organiser Taher Yousri. Amarjit Anand will be involved in organising the renowned London Imperial Spine Meeting in 2015. The Annual Lister/QE2 Hospital Regional Academic Meeting and Dinner organised by Akash Patel and Lily Li, with Consultant Mr Harish Parmar chairing the event, was extremely successful and well attended by approximately 40 SpRs and Consultants from the Northwest Thames region.

The prestigious Lipmann-Kessel Prize was awarded to Nirav Patel on his presentation on ‘The cost and clinical effectiveness of MRI in occult scaphoid fractures: a randomised controlled trial’.

Imperial College have continued making strides in their simulation training at the Simulation Laboratory at Charing Cross Hospital run by Professor Justin Cobb and Mr Chinmay Gupte. Numerous simulation courses for trainees have been run throughout the year with great success and feedback. Honorary Clinical Lectureships have been awarded to Amarjit Anand, Akash Patel & Khaled Sarraf for their role in teaching & simulation training.

We would like to welcome 9 newly appointed ST3 trainees onto the NW Thames rotation. Ahsan Akhtar, Khalid Al-Dadah, Donald Davidson, Rafik Fanous, David George, Alexander Magnussen, Piyush Mahapatra, Ravi Popat, Michael Shenouda, Rahul Singh, Quen Tang and Rupert Wharton. Congratulations to them.

London North East Thames (Royal London)John Stammers

It has been a good year for the Royal London Rotation. Congratulations to Charlie Jowett and Sam Heaton for passing the FRCS. Hopefully their 100% first time success will continue for the rotation in years to come.

Socially our annual Knees Up in November serves to introduce new trainees to the rotation and provide some basics in professional development. Alongside a few beers we had some great talks on getting published, the killer portfolio and the perfect CV.

Royal London trainees were instrumental in the organisation and success of the Royal London FRCS(orth)Trauma course and a Practical Introduction to Orthopaedics.

We are fortunate to have Pete Bates as the 2014 BOTA Trainer of the Year. His commitment, enthusiasm and passion to teaching is a great asset to the rotation and to any trainees lucky enough to work with him.

We recently celebrated our Royal London Hospital Orthopaedic and Trauma Society (RLHOTS) 7th Annual Academic meeting at the Kensington Roof Gardens. We were fortunate to attract eminent specialists from around the country including Mark Jackson, Martin Porter, Peter Brownson and Vikas Khanduja. The highlight of the meeting was the internationally acclaimed, award winning author Bill Bryson sharing his thoughts on ‘Bear Attacks and the Perfect Doctor.’ He also reminded us that the NHS is one of Britain’s proudest achievements.

We presented our RLHOTS trainer of the year 2014 to Mark Loeffler from Colchester General for his commitment to fighting the trainees’ corner and almost 20 years of teaching many trainees who are now consultants around the rotation and beyond.

This year we have started the “RLHOTS Training Hospital of the Year” with objective methodology used to compare which hospitals are providing “what trainees want.” Our inaugural RLHOTS Training Hospital of the Year was awarded to Queens Hospital. Following this year’s pilot we plan to make it a regular feature of the annual meeting and serve to reward hospitals committed to teaching.

Congratulations to Nic Wardle and Mabs Alam on your recent consultant appointments. Good luck to Wisam Al-Hakim, Claire Middleton, Shafic Al- Nammari, Alasdair Thomas, and Ed Britton on your fellowships. We look forward to welcoming six new Royal London Trainees in October.

There has been an epidemic of marriage and babies around the rotation this year! Congrats to Jag Singh, Natasha Picardo and Sam Heaton on tying the knot. Good luck with nappy changing Simond Jagernauth and Charlie Jowett on the birth of your son, Joshua and daughter Matilda, respectively!

London North East Thames (Stanmore)Atif Malik

The past 12 months proved a bumper year for Stanmore trainees in the FRCS (Tr&Orth) with success for Messrs Sewell, Hanna, Malik, Khan, Jaiswal, Welck, Gikas and Phillips. This was a reflection of the support and guidance received not just from our PD, Prof Briggs, but also the efforts of Mr Ferris and the excellent teaching

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programme. The teaching programme culminated as is usual, with an excellent Seddon society meeting.

For many of us, myself included, this brings an end to an amazing six years of training and as we head to new pastures, the baton passes onto our junior colleagues. As you may have gathered, this will be my last linkman report and I can honestly say it has been a pleasure and honour to be associated with such an esteemed institution.

Last but not least, the tireless hard work of Rosemary Radband must also be mentioned as I am sure all Stanmore trainees will join me in appreciating her devotion to her trainees.

Gone but not forgotten.

London North East Thames (UCH/Middlesex)Sean Phelan

Out with the old, in with the new.

Following last year’s success with the FRCS exam, the seniors have been slowly falling off the top or heading off on Fellowship with Sujith Konan in Vancouver on an Arthroplasty fellowship and Liz Ashby on a Paediatric Orthopaedic Fellowship in Montreal. Julian Leong has just completed the Exeter Spine Fellowship. Rhodri Williams is off the radar, married and allegedly somewhere back in Wales on fellowship. Claire Fitzgerald has just completed the Cobiella Shoulder Fellowship, got her visa to cross the murky Thames, and has taken up a shoulder fellowship at Guy’s and St. Thomas’s. Her leaving present was a survival kit and bulletproof jacket. We are currently assembling an elite team to retrieve her. Alistair Hunter has been appointed to the Chelsea Hand Fellowship and has also lined up the Wrightington Upper Limb Fellowship for next year.

As they leave, we must welcome and congratulate the following on being awarded their number and joining the rotation: Luthfur Rahman, Adit Prinja, Cat Fortescue and Antony Raymond.

The notable exam success was Paddy Subramanian being awarded his MSc by Oxford University. However, this may have been in anaesthetics as evidenced by the effects of his cocktails on the unwary. He has also with much gusto and diligence taken over the role of social secretary.

Mr Saksena at Chase Farm won “Trainer of the Year”, with Mr Youngman at UCH coming a close second. Otherwise, Mike Elvey won “Best of the Best”, which he will be presenting at BOA in September.

Finally, the Institute of Sports, Exercise and Health celebrated its first year by hosting the EFORT travelling fellows in May and organising the ISEH 5K Charity Fun Run in Regent’s Park, on a glorious summer’s day in June.

After what seems to be an eternity on this rotation, I myself must finally take a bow and hand over the reigns to my successor who will be named in due course, while I head up North for some fresh air.

London North East Thames (Percivall Pott)Steve Kahane

Four new ST3 trainees joined the Percivall Pott rotation in October 2013. We welcome Zac Silk, Mustafa Rashid, Babar Kayani and Simon Fleming, all of whom ranked highly at national selection helping to further strengthen our rotation.

We have had a strong record in the FRCS and are proud to congratulate Mr Ioannis Pengas and Mr Marcus Baker on their success this year.

One of the strengths of the Percivall Pott Club is its Annual Scientific Meeting, which is now in its 42nd year. Organised and led by the trainees, this meeting allows research from within the rotation to be presented. Last year, the meeting was held in the historic Great Hall of St Bartholomew’s Hospital.

Mr Mustafa Rashid was awarded the Charles Manning prize for best research presentation for his work entitled “Rotator Cuff Repair Leads To Muscle Regeneration On A Cellular Level: A Combined Histological, Radiographic And Functional Outcome Pilot Study.” His work has been submitted to the “Best of The Best” competition at this year’s BOA congress and we wish him the best of luck.

At the last meeting, we were honoured to welcome an excellent line up of speakers, including Prof Reinhold Ganz, Dr Peter Millett, Prof Gordon Blunn, Prof Jeremy Fairbank, Dr Ronald van Heerwaarden, Mr Paul Allen, Mr Keith Tucker, Mr Tim Theologis and Mr Martin Bircher. Our forthcoming meeting will be held on Friday 14th November 2014 and we already have some excellent speakers confirmed.

Our regional Trainer of the Year was Mr Charles Aldam of The Princess Alexander Hospital, Harlow. He works exceptionally hard to help trainees that visit Harlow and we are delighted this has been recognised.

This year, we have strong representation on the BOTA committee, with three of our trainees holding elected posts. Mr Mustafa Rashid has been elected Vice-President after spending a year as Education Representative. Mr Simon Fleming took over from Mustafa and was elected to the post of Education Representative and I have been elected to the post of Treasurer. This is excellent for the rotation and demonstrates the strong sense of leadership and initiative that this rotation aims to foster.

Our thanks finally go to our training programme director, Mr Pramod Achan, who has just recently returned from his ABC fellowship. The rotation has now even stronger links with the USA than ever before and it is hopeful that more of our trainees will take the opportunity to visit our colleagues across the pond for research and fellowships.

East AngliaSimranjeev Johal

The past year has seen a number of new Consultant appointments in East Anglia. Professor McCaskie has joined Addenbrooke’s, Cambridge, and has a specialist interest in stem cell therapy in Orthopaedics. Chris Gooding also became a substantive lower limb Consultant at Addenbrooke’s. Mr George Smith joined Norfolk and Norwich university Hospital as their second foot and ankle surgeon and Mr Iain McNamara was appointed as a senior lecturer and knee surgeon in Norwich. Miss Lora Young was appointed as a shoulder surgeon in Bury St Edmunds.

The region also lost some excellent consultants through retirement. Prof Rushton (Cambridge), Mr Keith Tucker and Mr John Albert (Norwich) and Miss Clare Marx (Ipswich) will be missed by all the trainees past and present. Miss Marx also made history by becoming the first female president of the Royal College of Surgeons England and is due to take up post in July 2014. Of equal note, she was also voted regional trainer of the year.

We welcome the new ST3 trainees to the rotation and say farewell and good luck to those leaving the rotation including myself (Sim

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Johal), Henry Budd, Tim Harrison, Praveen Inaparthy. Fellowships await and further challenges lie ahead. FRCS passes since the last yearbook include myself (Sim Johal), Emmet Griffiths, Paul Robinson, Chris Lawrence, Emma-Kate Lacey, Con Loizou, Pete Domos and Ed Spurrier.

The last regional meeting (Cambridge Orthopaedic Club) was held at Sidney Sussex College, Cambridge. The Prize presentation was on Issues Surrounding Consent for Children in Care, work carried out by myself. We also had a record turnout for the college dinner afterwards that went on until the early hours.

We welcome the next year with eager anticipation.

Kent, Surrey and SussexAbhinav Gulihar

The KSS orthopaedic program started 3 years ago after splitting from SW Thames and SE Thames rotations and includes all hospitals south of the M25. We have just had the fourth round of recruitment to the rotation with the appointment of fourteen more trainees.

We welcome the appointment of several new consultants in the region: Mr Aiyenuro (foot and ankle) and Miss Kate Gill (hip and knee) to the Royal Surrey County Hospital, Mr Rishi Chana (lower limb arthroplasty) to the Ashford and St Peter’s hospital, Mr Philip Wraighte (lower limb arthroplasty and trauma) and Mr Madhu Rao (lower limb revision arthroplasty) to the Western Sussex Hospitals NHS Foundation Trust (Chichester and Worthing).

In addition, we say farewell to Mr John Shepperd who retired earlier this year after supporting registrars in the SE Thames and KSS regions for more than a decade. Mr Iain McFadyen, an excellent trainer leaves the region’s Level 1 Trauma Centre (Brighton) in July. He will move to North Staffordshire to take up the post of Chief of Trauma. His enthusiasm, willingness to train and expertise will be greatly missed.

There were three registrar research presentation meetings in the last year held jointly with either the SE or SW Thames rotations. The Raine meeting was held on 6th December 2013 at St George’s Hospital chaired by Mr Dominic Nielson. The Sam Simmonds meeting was held on the16th of May at the Roehampton club while the Fred Heatley meeting was held at Herstmonceux Castle on the same date. We feel very proud to have awarded a trainer of the year prize for the first time this year. Mr Ben Rogers was awarded this prize at the Sam Simmonds meeting in recognition of his unflinching support to our training and education.

The KSS trainees won various research prizes this year. Congratulations to Mr Sohail Yusuf for being awarded the best poster prize at the BOA meeting, Mr Chris Gee for winning the best paper at the BOTA/FORTE session at EFORT, Mr Jonathan Quayle for winning the Raine prize, Mr Asim Khan for also winning a prize at the Raine meeting and Mr Will Kieffer for a third place finish at the Sam Simmonds meeting. We hope to see even more prizes in the years to come now that a research collaborative has been set up under the leadership of Mr Ben Rogers and Mr Matt Solan with a goal “to promote and facilitate high standard orthopaedic research in the KSS and SWT regions”.

KSS trainees also achieved honours in the field of education. Miss Amy Garner was awarded a ‘distinction’ from the University of Oxford for a Post Graduate Diploma in Teaching and Learning in Higher Education and Mr Shibby Robati was awarded a health education award by the East Kent Hospitals University NHS Trust.

WessexToni Ardolino

Firstly congratulations to those passing the exam; Alex Aarvold, George Cox, John Grice and Sam Yasen. Also to those who have had success in obtaining consultant posts, Toby Briant-Evans in Basingstoke and Winchester and Paul Pavlov in Lincoln.

There have been lots of other achievements by Wessex trainees this year. Duncan Avis, Mike Kent and Alex Nicholls all completed their MSc in Trauma Surgery from Swansea University, with Alex and Duncan obtaining merit. Sam Yasen was appointed as a fellow to the Higher Education Academy as well as completing a PGCE in medical education from the masters course at Bristol University.

Alex Aarvold and Neal Jacobs were awarded a BOA Ram Kumar Chattergee travelling fellowship of £5000 and we look forward to hearing their accounts on their return. James Smith won the KSSTA Editor’s Choice Paper Awards 2014 for best paper published in the KSSTA journal 2012-2013 for his paper; “Osteotomy around the knee–evolution, principles and results”.

Jo Higgins spent 6 months out of programme as a simulation fellow setting up a simulation training programme for the core trainees in Wessex. She has also run several simulation days for registrar and foundation trainees as well as establishing our regional JRI sponsored “Wessex Orthopaedic Trainees Journal Club” which meets regularly.

Nikki Kelsall set up the first Wessex FRCS examination course which received excellent feedback and is being run again in September due to its success. Jim Turner has helped develop and teaches on a surgery course for General Practitioners which is affiliated with the Royal College of GPs.

Wessex Orthopaedic Women continues to meet regularly, we have been fortunate to have receive support from the Women in Surgery team based in the Royal College and have had several interesting dinners with speakers and are starting to share ideas on how we can collaborate to help trainees return to work after being out of programme.

John Grice was the England men’s hockey doctor for the World Cup qualifiers in Malaysia, they won silver and qualified for the World Cup.

Congratulations finally to some proud trainees; Nick Evans on the birth of his twins, Neil Walker who has also had twins, Jo Round and Nikki Kelsall on the safe arrival of their babies, and Anthony Gould for the acquisition of his black Audi A5 S-line, 3.0L V6 Quattro with tiptronic gearbox, cream leather interior, 19 inch alloys with low profile tyres, and the full Bang and Olufsen sound system.

Thank you to all those who contributed to this and apologies as ever to all those who have been missed!

OxfordRichard Craig

Oxford continues to live up to its reputation for high quality care, research and training both for national training and for postgraduate degrees. With the COOL project linking us to healthcare initiatives in East Africa, we have truly international opportunities which trainees can get involved in and we continue to have a thriving link for Maltese trainees to work alongside us in Oxford.

In September we were pleased to welcome Nick Beresford-Cleary and Adrian Kendal to the rotation as they, together with Alex Hazlerigg,

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achieved full-time numbers in Oxford. We congratulate Lee Bayliss, Nick Riley, Paul Monk, Noel Peter, Rantimi Ayodele, Chris Brown and Graham Sleat who all completed the FRCS this year.

Elsewhere, Oxford Trainees have also been gaining national and international awards. Geraint Thomas brought back the John Charnley award from the American Academy, Lee Bayliss has been awarded a British Orthopaedic Oncology Society Travelling Fellowship, and Ben Dean won the podium presentation prize at the BOTA Annual Conference.

As usual, the focal point of the year is our annual Duthie Day. Thanks to Phil Wilde for organizing an excellent programme. John McMaster gave us a personal insight into military trauma care from his experiences in Afghanistan and David Skinner gave us a fascinating modern history from his 20 years of A&E in Oxford. Don Wallace shared his own first-hand account of living with a tibial malunion and we were fortunate to benefit from Robin Allum’s ACL pearls in his retirement year.

Registrar research presentations ranged from some high science through to a more light-hearted look at the prevalence of psychopathic personality traits in doctors. The prize winning talks were given by Salma Chaudhury for her work on nano medicine targets and Adrian Kendal for his work on mortality rates after hip resurfacing arthroplasty. To conclude the day we were privileged to hear Nigel Rossiter give a wonderful “Duthie Lecture”. His anecdotes of Oxford surgeons both past and present entertained us all and we also heard many useful lessons learned from both conflict medicine and his experience of trauma care in the UK.

At the evening dinner event we were delighted to announce Rachel Buckingham as our trainer of the year. This year she stepped down as Deputy Programme Director and lead of the regional teaching programme. Her tireless effort led to the programme achieving the highest level of feedback in the GMC survey.

A final huge thank you goes to Andy Wainwright, our Training Programme Director. As trainees we are fortunate to have such generous support throughout the programme, whether it be in the anxious ARCP or just a chat over tea on a Wednesday afternoon. He has even recently completed an MSc in Surgical Education and his essay on “A Good Pair of Hands” earned him the Robert Jones Medal from the BOA. He explores some of the less tangible points of training and the art of becoming a good surgeon. It is well worth a read for us all.

South West PeninsulaTimothy Woodacre

The 2013-2014 year has been a busy year for Trauma and Orthopaedics in the South West Peninsular Deanery. The regional trauma network has developed, leading to increased co-ordination between the regional trauma centre based in Derriford Hospital (Plymouth), and the regional trauma units based in the Royal Devon and Exeter Hospital, Torbay Hospital and the Royal Cornwall Hospital.

Orthopaedics is expanding in the SW. In Cornwall there is a strive to create a tertiary referral centre for hand surgery, aided by the appointment of a plastics-trained hand consultant Ms R Dunlop to add to the already experienced hand team. Spinal surgery is developing with the appointment of an orthopaedic spinal surgeon, Mr H Sharma to the spinal unit in Derriford Hospital, Mr O Stokes to the Exeter Spinal unit and the joining of the Exeter and Taunton on-call regional spinal services. I would also like to congratulate Mr R Hawkin in

his appointment to the Royal Cornwall Hospital as a consultant hip surgeon, with a specialist paediatric interest.

Several meetings have met with great success when hosted in the south west, including the South West Spinal Meeting (Cornwall 2014), the 3rd National Peninsular Trauma Meeting (Plymouth 2014) and the South West Orthopaedic Club (Plymouth 2014). The South West Orthopaedic Club’s inaugural outdoor swim meet was won in style by Mr M Norton, to add to his iron man achievements.

Registrar training has continued to improve and diversify in the south west. Trainees are now being offered training in 5 different hospitals, with the re-inclusion of Barnstaple Hospital in North Devon into the rotation. I would like to offer my congratulations to Miss E Mounsey, Mr N Jagodzinski, Mr S Middleton and Mr J Kosy for successfully completing their FRCS examinations.

Finally I would like to highlight the south west regional trainee of the year. The winner of 2011-2012, Mr Michael Regan (Truro) was nominated for a record 5 years in a row, however he was eventually beaten by the outgoing Programme Director, Mr James Davis, who was nominated due to his revolution of registrar training in both Torbay hospital and across the region during his time at the helm.

SevernNathanael Ahearn

This has been another great year for the Severn Deanery, a deanery that continues to provide a thoroughly enjoyable experience for all trainees on rotation. There have been plenty of changes, and indeed the Severn Deanery does not officially exist anymore. We are now part of the newly formed single Local Education and Training Board (LETB) for the South West combining both Peninsula and Severn, which is headed up by the Dean of the former, Professor Martin Beaman. Despite this the rotation has not changed significantly. We are lucky to have a superb, highly pragmatic TPD in Mr Mark Crowther, who is acutely aware of training needs and works hard to ensure the excellent standard of training persists. The outgoing head of the Severn School of Surgery, the brilliant Professor Richard Canter will be sorely missed. He has been replaced by our previous T&O TPD, Mr Steve Eastaugh-Waring, who undoubtedly will be sympathetic to the needs of orthopaedic trainees in the region!

The teaching programme co-ordinated by Jason Webb has delivered great rewards in the exam setting, with Alanna Pentlow, Hideki Nagata, JJ Gillooly, Damian Clark, Andrew Hughes, Mark Kemp, Riaz Ahmed, Luke Brunton, Jim Aird, Ewan Bigsby and Neil Uphaday all successfully navigating the potential minefield of the FRCS (Tr&Orth) exam. Mr Webb attended the most recent BOTA educational weekend, and together with Mr Michael Whitehouse produced an award winning small group workshop. The training programme has enabled a significant number of trainees to secure substantive consultant jobs, both in and out of region. Congratulations to Michael Whitehouse, Tristan Barton, Tom Quick, Will Thomas, David Thyagarajan, Stephen Morris, Adrian Hughes, and Jayne Ward.

The Severn Audit & Research Collaborative in Orthopaedics (SARCO) has been established and produced its first collaborative project, with contributions from all the hospitals on rotation, and our annual research presentation day saw prizes awarded to Julia Blackburn, Lynn Hutchings, and Jemma Rooker.

The local registrar group, BORG, led this year by Andy Stevenson, continues to go from strength to strength. The social calendar has expanded significantly from the usual post-teaching Friday afternoon

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in the Cambridge Arms. Our annual publication JBORG has once again provided highlights of the rotation’s successes. We now have a social media presence on Twitter (@Official_BORG), and to top it all off BORG won the annual consultants vs registrars golf day featuring a hole in one from Jim Aird!

Mr Simon Thomas, from the Bristol Children’s Hospital (BCH), was the deserved winner of our trainer of the year. The BCH has monopolised this award for the past few years, a testament to the quality of training and enjoyment of trainees passing through the unit. Unfortunately one of the stalwarts of the unit, and indeed UK orthopaedics, Mr Martin Gargan, is leaving to take up a professorship in Toronto. It is impossible to summarise his impact on the rotation, as this would constitute a significant article in itself, but he was TPD for several years, won the BORG trainer of the year on multiple occasions, and remains an inspirational figure for all local trainees. He will be sorely missed by all and Bristol orthopaedics just won’t be the same without him. We wish him all the best for the future.

WarwickDan Westacott

2013-14 saw another successful season for the Warwick rotation. We were pleased to welcome the fresh legs of Chris Downham, Rajiv Gogna and Tarek Boutefnouchet to the rotation, along with the journeyman Dan Perry, who is now thriving on fellowship at the Hospital for Sick Children in Toronto.

We congratulate Xavier Griffin on his success in the FRCS (Tr&Orth) and look forward to more of his inimitable insights on his return from a pelvic and acetabular fellowship down under.

Congratulations are also warmly extended to old boys John McArthur and Panos Makrides, who start their Consultant posts in August at University Hospital Coventry and Birmingham Heartlands Hospital respectively.

Our academic trainees at Warwick Orthopaedics have enjoyed a productive year under the auspices of Professors Costa and Griffin, continuing to contribute work of unprecedented quality to the musculoskeletal evidence base.

Our cadaveric courses at the West Midlands Surgical Trainee Centre continue to increase in popularity and we look forward to welcoming trainees and Consultants alike from across the country next year.

East Midlands South (Leicester)Reshid Berber

The East Midlands South (Leicester) region has had a year of firsts, and many successes.

First of all we would like to congratulate Professor Jeya Palan for a successful year as BOTA president. He has passionately put his efforts into this role over the last year, ensuring the voice of trainees across the country has been heard. Nick Ferran also enhanced Leicester’s presence at BOTA as the SAC representative; we congratulate him for a successful year in this role. In particular, Nick has been instrumental in the adaptation of the ISCP in its merger with OCAP over the years, helping to smooth the transition and benefiting all trainees in doing so.

As a region, we are very proud with our progress in developing an excellent training programme, having been recognised in the national scoring grid with a 3rd place finish. We would like to thank Prof Joe

Dias, immediate past president of the BOA, and Mr Bhaskar Bhowal for their continued support and efforts in this. We pride ourselves on great cooperation between trainee’s and trainers in improving our programme. The trainee’s voice is heard through the Leicester Orthopaedic Trainee’s Association (LOTA). Dev Mahadevan, Amit Kumar, Randeep Aujla and myself have led this as Linkman.

Evidence of improvements within the programme include the development of the pioneering e-Tool Virtual Learning Environment for T&O, allowing trainees to complete case based discussions for the curriculum specified ‘critical conditions amongst other things. We would like to thank Lucy Cutler, Jenny Nichols, Veronica Roberts and Jose Blanco for their efforts in developing this excellent tool.

We have organised and held our inaugural East Midlands South Orthopaedic Research Day, where trainees showcased all the excellent research being undertaken. We thank the efforts of Rob Ashford and the Specialty Training Committee for making this day possible, and also Ben Bloch and the LOTA committee for their efforts in putting the programme together. Congratulations are extended to Laurence Wicks, winner of the Aesculap Academia Travelling Fellowship. In addition to this, further recognition is given to Nick Ferran, who was awarded the Joe Harper Plate, as recognition for consistently achieving above what is deemed satisfactory throughout his training.

We would also like to extend our recognition of the efforts of Rob Ashford, Patricia Allen and Ben Bloch for revamping our teaching programme, helping the Leicester region to maintain a healthy track record in the FRCS examinations. Congratulations to all those who have passed this exam, which would not be possible without the personal contribution from several of our most respected trainers. As a region we are once again proud that a Leicester Trainer was voted runner-up for the National Trainer of The Year Award for a second year running (Mr Christopher Kershaw).

We thank Richard Barrington and Simon West for their contribution to the training programme and the STC over the years and wish them all the best in the future. Lastly, I would like to personally welcome the new trainees joining our region, and wish those trainees who are very soon to complete their time in the region having achieved CCT the very best in the future.

East Midlands (Nottingham)Faiz Shivji

2014 has been another fantastic year for the East Mids North deanery. We’d like to firstly congratulate Jim Brousil, Nick Duncan, and Simon Booker for passing the FRCS. Nick and Simon have also become fathers for the first time, which caps off a memorable year for them!

The deanery continues to have academic success. The Malkin Memorial meeting took place in July in Nottingham, which showcased many presentations by trainees, highlighting the current research being undertaken in the deanery. The prize for best presentation was awarded to Tom Kurien.

Tom Kurien has also been awarded 2 fellowships for his PhD, the MRC Clinical Research Training Fellowship and BASK fellowship. In addition, Darryl Ramoutar was awarded the BOA Trauma Travelling fellowship this year. Darryl also completed his MSc in Orthopaedic Engineering along with Andy Titchener.

Nottingham was the host of this year’s British Elbow & Shoulder Society Conference, which was a great success, featuring expert guest lectures and the latest in clinical research.

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Finally, we must congratulate the trainees involved in working at the Queen’s Medical Centre, which has become one of the largest Major Trauma Centres in Europe. The trainees’ relentless hard work has helped deliver world-class trauma healthcare, and placed the QMC in the top 5% nationally with regards to clinical outcome measures.

We look forward to the new recruits joining us in August: Simon Craxford, Avi Das, and Laura Johnston, welcome to the deanery!

West Midlands (Birmingham)Shahbaz Malik

Last year was busy but a routine academic year. Here are the highlights from the rotation.

Congratulations to the following trainees for passing the FRCS (Tr&Orth) exam from Birmingham rotation: Karanjit Mangat, Samuel Chan, Simon Maclean, Tahseen Chaudhry, Zaki Choudhury.

Congratulations also to Usman Ahmed (ST4) who successfully defended his thesis and was awarded a PhD in Medicine from the University of Warwick.

Birmingham Orthopaedic Training Programme (BOTP) Trainer of the Year Award went to Mr Bhuvan Machani (Sandwell & West Birmingham Hospitals NHS Trust). The winners were selected by asking the trainees to assess their selected Trainers against the following domains:

• Teaching ability (clinics/lectures)

• Teaching ability (operative)

• Support and advice

• Research and audit

• WBA completed

• ISCP engagement

• Recommendation to colleagues

Each domain was awarded a mark and the marks were then calculated at the end to select the winner. The overall response was good from the trainees and it ensured an objective way of selecting a TOTY.

Usman Ahmed (ST4) was awarded one of the SICOT UK Trainee Meeting (London, June 2014) Travelling Fellowship Awards for his presentation “A simple biochemical algorithm for the detection of early-stage osteoarthritis”. Gulraj Matharu (Academic Trainee) was awarded poster distinction at EFORT, London, June 2014 for: Predicting high blood metal ion concentrations following metal-on-metal total hip replacement. Gulraj also won the podium presentation prize at June 2014 Naughton Dunn meeting for the above presentation.

Jowan Penn-Barwell and Ben Rand are leaving the Birmingham rotation and will be joining Northern Deanery as part of a military shuffle. They will be missed on the rotation, but hopefully we will get more cutting now that they have left. We wish them well. Gulraj Matharu will be leaving the programme for full-time research at the University of Oxford from August 2014 and has been awarded The RCSEng Research Fellowship, which will help fund this.

We would like to welcome the new ST3 to Birmingham rotation, starting from August 2104. We hope you will enjoy your time in training in this friendly and diverse rotation. The new ST3s are: Basil Budair, John Lynch, Sheila Vinay and Shakir Hussain.

We would like to wish good luck to 5 CT2s and a LAT, who were successful in obtaining a ST3 T&O NTN through the National Selection

process. Congratulations to: Niraj Vetharajan, Gopikanthan Manhoar, Tofunmi Oni, Toby Jennison, Ran Wei, Shakir Hussain (LAT).

And as all good things do, my tenure as BOTA linkman for Birmingham has come to an end and the baton has been passed onto Mr Guy Morris who will do his utmost to keep his revolutionary tendencies in check as he becomes the trainee’s champion.

Oswestry and StokeRoss Fawdington

This year has seen the University Hospital of North Staffordshire (Stoke) going from strength to strength. It has been appointed to takeover the management of Stafford hospital and redevelop its’ services. Stoke has also been acknowledged as the busiest major trauma centre in the UK, with the highest number of ISS > 15 patients (Injury Severity Score). The Accident and Emergency department is also the first in the country to be awarded an Excellence in Practice Accreditation Scheme (EPAS) award for the care provided to patients.

Orthopaedic training at Stoke is still very strong and trainees are given the opportunity to manage complex trauma but also have expert supervision readily available. The on call and fracture clinics are incredibly busy however, once up to speed a trainee will feel confident to manage any orthopaedic conditions.

The Oswestry programme of training is focussed on academic excellence and exam trainees are grilled for 30 minutes every morning in the plaster room. Friday afternoon teaching is a structured complex case conference, where consultants bring their most interesting cases for the exam trainee to examine and the other consultants to offer second opinions.

The FRCS pass rate remained unblemished and our thanks go to those consultants who tirelessly make every effort to ensure we succeed. Our regular teaching is supported by both pre- and after work training sessions on specialist areas and all consultants that have been approached, have given their time and prepared material for topics that the trainees are struggling with.

Our research day was well attended and demonstrated the huge volume of work that our trainees are doing. Mr Thom Moores won the research day prize for his project titled, ‘Infection in Arthroplasty, does it start whilst scrubbing? A microbial assessment using particle counts and cultures of sterile surgical hood systems.’ This demonstrated that having the hood fan switched on while scrubbing and gowning distributed particles that could lead to infection.

MerseySimon Robinson

Mersey deanery would like to start by congratulating David Machin, the past BOTA President, as he has received his Golden Ticket and is currently healing the feet and ankles of south Cheshire. The people of Crewe are a little surprised to see his name badge attached to an exact replica of the BOTA president chain and medallion, but he alcogels it first and tucks it under his tie to appease infection control.

There have been a good number of successes at sitting the test over the last year. I would like to congratulate Feisal Shah, Phillip Holland, Alan Highcock, Roger Walton, Daniel Withers, Geraint Williams, Grev Farrar, Daniel Gheorghiu, Paul Jermin and last but not least Simon Robinson. If I’ve forgotten anybody I apologise.

The 2013 Registrar day was a roaring success with the high standard of research and presentation skills on show. The 58 ball followed the

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Registrar day and was enjoyed by all who attended. The 58 society has been run by Noddy for 2 years and he has handed the reigns over to Nick Peterson who has a hard act to follow.

The Mersey trainer of the years is awarded at the 58 ball and this year’s winner was Mr Cope, a consultant at Southport Hospital. He has worked hard in a small department to improve the training offered. His job is now seen as a must if you would like to specialise in the field of lower limb arthroplasty.

New trainees in the region elected to the BOTA committee are James Shelton [Secretary] and Sara Dorman [Publicity], who are continuing Mersey’s reputation of having a strong presence within BOTA. Overall this has been a good year for Mersey and l hope it continues.

North WestRonnie Davies

This year started with our TPD, Mr W Ryan, attending his second TPD forum. Since starting, he has continued to develop the training programme, facing issues such as indicative numbers and the new curriculum. Paediatrics, spine and hand surgery attachments have each been extended to 6 months to ensure sufficient exposure to all specialties prior to the exam.

Success has continued in the FRCS for North West trainees. Congratulations to those who have recently passed. This is a reflection of the high standards of our excellent teaching programme, organised by Mr David Johnson. The year 4 exam-focused teaching is run by Mr Ravi Goyal. A new post-exam teaching programme run by Mr Aqeel Bhutta focuses on professional and management issues, helping senior trainees to prepare for consultant interviews. Compulsory attendance at the educational component of the BOTA conference was popular with trainees last year and will continue.

Three hospitals in the North West are now getting used to working as a major trauma collaborative. Despite the diversion of polytrauma to these hospitals, unlike other regions, we have not seen a major decline in trauma in other centres, or a negative impact on training. On-calls have generally remained non-resident, including at most major trauma centres.

The annual research day showcased the high quality of research in the region. Mike Anderton (ST5) won two prizes, including best paper, and will present his work at the ‘Best of the Best’ session at BOA/EFORT in June. The Bluespier Research Prize entered its fourth year and was won by Jon Baxter (ST6). As usual, the research day was followed by the annual ball, which was again extremely well organised and attended (thanks to Ben Fischer, Tom Finnigan and James Childs). Ed Yates won the coveted honour of trainee of the year. This year saw the launch of the North West Orthopaedic Research Collaborative, headed by Professor Tim Board and Mr John Gregory. It aims to improve access to advice, funding, and statistical support and provide a mechanism to run regional trials across multiple centres.

Our regional trainer of the year award went to Mr John Henderson (Consultant T&O with a special interest in paediatric surgery) from the Royal Bolton Hospital. He has been very popular with all trainees and will be sorely missed when he enters his well-deserved retirement.

Our local trainee website has been redeveloped. It provides all information on teaching, file downloads relevant to each teaching session. It also incorporates teaching feedback and attendance monitoring, enabling each trainee to view their own attendance record at a glance, and consultants to save their own feedback. It will expand over coming years to provide a comprehensive guide to the rotation and integrate with the research collaborative.

Finally, I would like to thank Mr Wiqqas Jamil for his work as BOTA linkman over the past 4 years. I took over from him last summer and his will be a tough act to follow. I look forward to working with the BOTA committee and representing NW trainees nationally.

NorthernRamsay Refaie

It has been another great year up North! I am pleased to report that training in the Northern Deanery continues to go from strength to strength. In addition to the UKITE which has been a fixture for several years now, the In Training Clinical Assessment (ITCA) was run for a second successful year. Post exam trainees continue to lead on this and thanks to the efforts of Balaji Puroshotman and Alan Cooney this year’s event was a huge success. The format is designed to mirror the FRCS clinical and was sat by all trainees from ST4 up with the ST3s observing and helping run the logistical side of things.

Our registrar prize day and dinner–the Kreibich day–continues to grow. This year’s event at Ramside Hall was extremely well attended by trainees and consultants alike and especially entertaining in large part thanks to our guest speaker Professor Angus Wallace. Prof Wallace not only gave a great lecture on orthopaedic innovation but also showed us some very innovative dance moves as the night went on! This year’s prize was won by Paul Rushton one of our ST3s for work he has done evaluating the Nottingham Hip Fracture score in our locality–watch this space as I am sure it will be in print soon.

Our trainer of the year award was hotly contested as ever and we must congratulate Dave Cloke from North Tyneside Hospital who won this year’s prize. Despite being a relatively new consultant he has managed to leave a lasting impression on our trainees who chose to recognise him with this year’s award.

There have been many successes in the FRCS examination and congratulations go to Aravind Desai, Paul Cowling, Simon Jameson, Simon Chambers, Tim Bonner, Suresh Thomas and Kiran Singhisetti. Dan Dowen also passed the exam which is all the more impressive given that his wife went into labour on the same day as his viva.

Another exciting development this year has been the emergence of CORNET–our regional trainee led research collaborative. CORNET was initially set up by Paul Baker who has handed over the reigns to co-chairs Will Manning and Matt Mawdsley. He is however keeping hold of the purse strings and will carry on as treasurer during this transitional period. CORNET are very excited to have secured funding to conduct a RCT which will be led by Alex Sims in collaboration with the Warwick Trials unit and a number of centres including Northumbria, Leicester, and Middlesborough, comparing the Thompson’s hemiarthroplasty to the Exeter Unitrax system.

2015 promises to be another great year and following the latest instalment of national recruitment we look forward to welcoming a number of new faces to our program.

South Yorkshire (Yorkshire and Humber)David Wood

Well it has been another busy year on the South Yorkshire rotation.

This year we welcomed Mr Chrishan Marriathas, Mr Malik Racy, Mr Madavan Papanna and Miss Sarah Barkley to the rotation. Chrish, Madavan and Sarah had undertaken their core surgical training locally before heading off to pastures new. Malik joined us from London after

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completing his core surgical training. All saw the light and came to the White Rose County. We are pleased to have them with us and look forward to watching their progress over the coming years.

This year we presented three candidates for the FRCS examination. We were thrilled to celebrate with Mr Andrew Legg, Mr James Fagg and Mr Gautam Tawari in passing the FRCS Trauma and Ortho at the first attempt. We were delighted to hear that Mr James Fagg had been awarded the Gold Medal for the highest score in the MCQ papers.

Congratulations to Miss Caroline Blakey and Mr Saif Salih on completing their MD’s. We were excited to celebrate with Mr Shanker Thiagarajah as he won the New Investigator Recognition Award at the 2014 Orthopaedic Research Society, New Orleans, USA.

We welcomed four new Consultants to the region: Mr Rob Simpson-White (Doncaster Royal and Bassett Law Hospitals, Hand Surgeon), Mr Howard Davies (Northern General Hospital, Trauma and Foot and Ankle Surgeon), Mr David (Northern General Hospital, Upper Limb Surgeon), Mr Michael Athanassacopoulos (Northern General Hospital, Consultant Spinal Surgeon)

Three of our recent trainees have been appointed outside the region: Mr David Bowe (Airedale General Hospital , Upper Limb Surgeon), Mr Anthony Cooper (BC Children’s Hospital, Vancouver, Paediatric Surgeon), Mr Martin Goddard (St. George’s Hospital , Trauma and Soft Tissue Knee Surgeon), Mr Aamer Nisar (Hull Royal Infirmary, Trauma and Lower Limb Arthroplasty Surgeon)

This year one of our eminent Senior Consultants retired from full time NHS practice: Former South Yorkshire trainee, Training Programme Director, FRCS Examiner and BOA Secretary Mr David Stanley retired after 25 years from the Northern General Hospital. We wish him and his family well for his retirement and thank him for his loyal service to the region.

This year our weekly Higher Surgical Teaching was organised and run by Mr David Bowe and Mr David Wood covering Paeds, Upper Limb, Trauma and Basic Science.

Our 24th Annual Orthopaedic Registrars’ Day was organised by Mr James Stoddard. Guest of honour was Prof Hamish Simpson. As always there was hot competition for the Getty Plate. It was eventually won by ST4 Mr Jonathan May presenting a mechanical study of DHS plate-bone interface stability with variable shaft screw trajectories. The runner-up was ST3 Mr Dominic O’Dowd.

The Nick Kehoe Travelling Fellowship was awarded to Miss Caroline Blakey for her trip to India. The Aesculap/BBraun Travelling Fellowship was awarded to Mr James Stoddard for his trip to USA.

A wonderful event was rounded off in style at Baldwins Omega with the evening’s James Bond themed black tie ball – complete with Aston Martins in the car park! Mr Andrew Hamer Consultant Lower Limb Arthoplasty at the Northern General Hospital was named Trainer of the Year for the second consecutive year.

Our Annual Consultant vs. Registrar cricket match was played at Hallam Cricket Club – a competitive game saw the Consultant team over run the Registrars to extend their winning streak to seven years. Battle lines will be have been redrawn by the time this goes to press!!

YorkshireSaif Hadi

Being the biggest deanery in the UK, both geographically and numerically always makes the Yorkshire rotation interesting due

to the wide variety of trainees and even more interesting variation in trainers! 92 miles from Halifax in the west to Scarborough in the East the rotation covers 11 major hospitals including 2 major trauma centres (Leeds and Hull). This gives the 67 trainees a wide experience of training and the ability to buff their logbooks in all aspects of Trauma and elective work.

This year Trainer of the year was awarded to Mr Ken Mannan, from Scarborough Hospital, North Yorkshire. He specialises in the lower limb with a subspecialty interest in Foot and Ankle. He is trainer to ST4’s who generally come straight from one of MTCs and so have not had a huge experience in independent operating. His laid back style with high level academic knowledge and his eagerness to let his trainee be 1st surgeon is why the trainees who have been through his watch have voted him Silver Scalpel this year.

Yorkshire continues with a 100% pass rate for the FRCS exam for the past three years running making up around 20 trainees who have come through without a hitch. The tight criteria required to be signed off mean that this tradition is likely to run for some time yet!

The Fitton Prize is annual presentation day which was won by Peter Loughenbury continues to draw high level research projects to be presented to a fearsome panel of judges. Congratulations go to him. And this is usually timed with our annual Consultants vs Trainees golf tournament. Last years outgoing Linkman Ben Brooke won this 5 years in a row so it’s a shame to now lose him to the Consultant side!

As with all regions there is perpetual concern for the number of trainees coming through the system and the number of substantive consultant posts at the end. This is even more alarming with the huge increase in trainees appointed to ST3 this year. So as with all of us, the future remains in doubt but very interesting!

South East of ScotlandVittoria Bucknall

We have had another great year in SE Scotland with excellent FRCS results, a new consultant appointment and the development of an excellent new teaching programme.

Mr Isaac Ahmed after his fantastic works with the college and his other impressive credentials has been appointed consultant at Royal Infirmary of Edinburgh and I am sure he will be a great asset. Mr Paul Jenkins has sadly left us but has been appointed a consultant in Glasgow, who are very lucky to have nabbed him. Mr Kash Kahn has been appointed a consultant in Aberdeen who are also fortunate to have him as a colleague.

The standard of teaching and training remains high with excellent logbook numbers, research publications and four great nominees for Trainer of the Year – Mr White, Mr Keating, Mr Cook and the winner due to the incredible work on our teaching programme was Mr Matt Moran. The innovative teaching programme saw a dull, dry Friday afternoon swapped for national speakers, interactive workshops, technological advances and of course a sponsored lunch!

The Edinburgh International Trauma Symposium continues to grow year on year. We also hosted our first Cartilage Symposium to produce a consensus paper on the latest cartilage techniques, this was well attended with excellent international speakers.

We are very proud of our training programme and hope this continues in the coming years. I am handing over the baton of BOTA linkman for SE Scotland to Miss Vittoria Bucknall, who I know will do an excellent job, as I take on a role with the Scottish Council for the BMA.

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East of ScotlandMichael Reidy

In the East of Scotland deanery this year we welcomed back Ali MacInnes having previously been an FY in the department. Sam Roberts and Fraser Harold have both been on fellowship and Simon Johnston, Amar Malhas and Gerry Cousins have all been successful in organising prestigious fellowships for the coming year. Sarah Gill has taken the opportunity to study for an MD in medical education and will return to the program in 24 months. We also welcome back Julie Smith following her out of program PhD in medical education.

A returning registrar, Mr Arpit Jariwala was appointed as a consultant and at the same time we welcomed Mr George Chami to the department.

Mr Donald Campbell took over as the TPD for the region and has been keen to gather trainee feedback from the trainees on their placements in order to better target successful trainee and trainer pairings. In addition a ‘halfway’ formative ARCP was introduced this year to assess progress and was found to be extremely useful for the trainees.

The third TORC (Tayside Orthopaedic Research Club) was a great success in November with the best attendance yet. We were very grateful to Mr Ricky Villar in his role as visiting judge and guest speaker.

After teaching drinks on a Friday has been replaced by bathtime for Gerry Cousins and Stephen Dalgleish as I am delighted to say they both became dads this year.

West of ScotlandFindlay Welsh

The last year has brought in several new changes in the West of Scotland. Our long standing Training Programme Director, Mr David Large has moved up to take chair of the SAC, with the TPD role now fulfilled by Mr Bryn Jones. Mr Large was TPD for 9 years, and guided the local trainees through several changes including MMC and the introduction of ISCP. His contributions as TPD will be missed, but he will undoubtedly do a commendable role for the SAC. Mr Jones has already implemented some new ideas with the initiation of a mentorship scheme, which has been welcomed and should help the new trainees integrate quickly into what is a large orthopaedic programme. On a sad note, Mr Gam Ayana, our Chair of the Postgraduate Committee is off on long term sick leave and we would all like to wish him well.

Congratulations are to be passed on to Iain McGraw, Alison Winter and Alex Augustithis who have all completed the FRCS clinical. Several trainees have now also secured consultant posts in the West: Mike Mullen at the Western, Jon Clarke at the Golden Jubilee, David Howie at Wishaw, Jen McGlynn at Hairmyres and both Stuart Bell and Jibu Joseph at the Royal Alexandria in Paisley. Two previous Edinburgh trainees have also joined the ranks in the West, with Paul Jenkins joining Glasgow Royal and Nick Olley joining the Golden Jubilee. There have also been moves at consultant level with Angus Arthur joining the Victoria and Duncan Macdonald joining the Southern General. Sadly, Gavin O’Neill has left for Singapore to continue his pelvic and acetabular work and will be missed at Hairmyres, and Alan Crombie has returned to New Zealand.

The next year will continue to be both interesting and turbulent. Two major sporting events will hit Glasgow and Gleneagles with the Commonwealth Games and the Ryder cup both happening in the

next three months. Hopefully these will bring good publicity to the area and provide a good spectacle for all sports fans.

The new Southern General Hospital is due to open next spring and will herald the move of the Victoria and Western Infirmary Orthopaedic departments to the new site. In line with the announcement of the 4 trauma centres in Scotland, the new Southern site will become Glasgow’s regional centre, which will hopefully continue to improve the management of major polytrauma. The existing Yorkhill Hospital for Sick Children will also move into new buildings on the Southern General site. This will be the largest infrastructural change to happen in Glasgow for decades. Upheaval will be expected, but the future for training should be bright with a new educational facility, closer links for research and the consolidation of trauma.

North of ScotlandChristopher Munro

This year has been eventful for those of us in training in the North of Scotland. We have welcomed some new consultants and continue to do so this summer as two of our previous trainees return from their fellowships to take up substantive consultant posts. We also say farewell to Miss Elliott, who leaves us after many years (both as a trainee and more recently as a consultant) to take up a paediatric consultant post in Southampton.

This ongoing increase in consultant numbers reflects the expansion our unit continues to experiences which also takes the form of increasing numbers of orthopaedic theatres at our elective site in Woodend Hospital. Two new theatres are to open imminently and this should positively impact on our training with more opportunities to operate than ever before.

Despite this however, several challenges remain. The expansion of our department is not matched by the fact that trainee numbers continue to decrease. Non compliance on our rota monitoring has unfortunately forced us onto a full shift pattern and away from the popular 24 hour on calls. Hopefully we can use this period of rota redesign to improve training in other ways and there continues to be a good dialogue between both trainees and trainers to attempt to ensure this is the case.

Congratulations are offered to our trainees – Santosh Baliga, Clare Miller and Katrina Treon who have passed (in whole or in part) FRCS T&O this year.

The mantle of our postgraduate teaching has now fallen to Mr Iain Stevenson and its revamp appears particularly popular with the trainees. It has become more involving and interactive, with regular viva and practical sessions. We look forward to the further changes he plans to implement in the year ahead.

Overall, life continues to be busy and challenging for trainees in our region. Despite the challenges we face, as in most regions, our experiences and training are overwhelmingly positive and we look forward to another year in the North of Scotland.

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WOC has had an exceptional year in 2013-14 to say the least. Its tentacles are spreading worldwide, with now an exciting new project in Ethiopia. It has issued an official constitution in line with the other BOA subsidiary societies and boasts a new website. It has launched an orthopaedic handbook specifically aimed at clinical officers, which is already in wide use across Malawi. We held a superb scientific meeting in the form of a highly acclaimed annual conference in May. And finally, it has been offered its own session at EFORT, which was well attended. Indeed, WOC’s profile is continuing to rise among trainees, as exemplified by the growth in membership as well as attendance to its events.

There were 4 main meetings:1. AGM at the BOA congress, Birmingham, October 2013

WOC continues to be a charity arm of the BOA and has its own dedicated slot at the congress, where the best abstracts dealing with global orthopaedics are presented. This is just a reminder to all trainees to look up that avenue for a podium presentation next year.

2. 3rd edition of Global Surgical Frontiers, 24th January 2014

GSF3 was ever so fascinating, with an exciting mix of presenters and exhibitors. The theme of the meeting was Surgical Training (in the UK and worldwide) and among the speakers was none other than Jeya Palan, talking about Shape Of Training as well as the recent clampdown of fellowships. This was followed the next morning by our executive committee meeting. Progress on the constitution and the annual conference were discussed. Plans were made to further strengthen the structure of WOC and its ability to assist with requests from the low and middle income countries (LMICs). We are working hard on the establishment of specific country reps.

3. Annual Conference, Leicester University, May 2014

This has replaced the yearly WOC extended executive meeting event and was undoubtedly the highlight of the year. All credits to WOC member Laurence Wicks for his immense work on this project. The first Ginger Wilson (founding member of WOC) memorial lecture was awarded to Steve Mannion – a largely deserved recognition for his tremendous contribution to global orthopaedics. We had excellent presentations about the orthopaedic efforts in Syria. We heard first hand accounts from Omar Gabbar and Mounir Hakimi who have founded their own respective relief organisations towards this work. We encourage you to look them up at:

www.handinhandforsyria.org.uk

www.syriarelief.org.uk

We heard country reports for Ethiopia, Malawi, Ghana, Ukraine, Palawan (Philippines), Bangladesh and Cambodia, all with great admiration and hope for the future. These are countries where WOC is particularly active and has a dedicated member coordinating activities there.

We also had two great fellowship reports from WOC-sponsored trainees. Simon Graham talked about his 6 months at Queen Elizabeth Central Hospital in Malawi and the fascinating projects he got involved in. James Turner spent a year just across the road at the charity children’s orthopaedic hospital, CURE. CURE in fact was awarded this year’s Telegraph charity Christmas appeal, a remarkable achievement.

4. EFORT

There was an amazing line up for the talks at the EFORT session in June with the world famous Norgrove Penny talking about advances made by The Global Clubfoot Initiative. We also heard about Syria and training in West Africa. We were finally treated to a first hand account of Disaster Relief Orthopaedic Surgery by none other than Steve Mannion.

WOC continues to remain involved in a number of activities worldwide, the key ones being:

COSECSA – (College of Surgery for Eastern, Central and Southern Africa). WOC has as one of its main missions to help with the delivery of surgical training in low-income countries. It sent examiners again this year to assist in the exams held in Zimbabwe.

WACS – (West African College of Surgery). WOC has consolidated its partnership with WACS and become more involved in teaching, examining and setting surgical standards–as it already does for COSECSA.

Global Clubfoot Initiative – This multi-NGO supported initiative keeps growing from strength to strength and now boasts more than 30 countries with programmes and greater penetrance for its established programmes.

IETR – This is a database set up by the Department for International Development (DFID) to ensure a coordinated effort for UK medical personnel to provide aid in the initial stages of disasters or conflicts around the world. The first major programmes coordinated by the IETR have taken place, including in the Philippines after cyclone Haiyan. Steve Mannion was on that mission and gave us a talk on it at the annual conference. WOC is working hard on facilitating release from trusts for enlisted consultants.

Primary Trauma Care – This is the low resource equivalent of ATLS which is now in practice in over 60 countries.

Finally, in the last month, WOC and BOTA have worked hard together to put out a position statement on the future of fellowships. This can be viewed on both BOTA and WOC websites and we encourage trainees to familiarise themselves with the document. We mainly lobbied for the preservation of OOPEs (Out Of Programme Experience), but also highlighted that OOPTs (Out Of Programme Training) should not be entirely ruled out.

WOC sadly lost one if its most committed members in the last year, Abbas Khan, who dedicated his life to the humanitarian effort in Syria died while in custody over there. WOC mourns such a tragic loss and indeed would like to dedicate this report to him.

World Orthopaedic Concern (WOC)Ashtin Doorgakant

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Background

It has come to the attention of the BOTA committee that some training regions of the UK do not allow their trainees to take part in ‘Out of Programme Experiences’ (OOPEs). Many such OOPEs involve humanitarian projects such as those organised by World Orthopaedic Concern (WOC) and the Kenya Orthopaedic Project (KOP). This position statement aims to makes clear the BOTA committee’s opinion that such OOPEs should be available to all orthopaedic postgraduate trainees in the UK.

Document

Most people become doctors because at some level they have a desire to help people in need. As such they work hard at school to make grades that permit entry to medical school. At medical school they work hard to pass each year before finally graduating. They then progress through foundation training before choosing and competing for entry into the subspecialty of their choice. Throughout this time, other than perhaps for a medical school elective or prior to specialty training, there is little opportunity to practice medicine or surgery in developing countries. Even if such an experience is arranged, the lack of specialty training means the ability to truly help is limited.

The expense of orthopaedic operations in the developing world and lack of first world support paradoxically makes orthopaedic missions to the third world a much needed resource. Orthopaedic trainees are well placed to step in to help those less fortunate than ourselves in that we have experience of higher surgical training, are at a stage of career with no fixed case load/service pressures and are more likely to have flexible home circumstances.

The Joint Committee on Surgical Training state that a trainee may take time out of programme provided it is agreed by the Deanery (LETB) and SAC.1 Indeed it actively encourages trainees to participate in experience overseas:

“The JCST encourages trainees to undertake time out in developing countries but would normally view this as experience not training. Time spent in a developing country will therefore normally be treated as Out of Programme Experience (OOPE), which would not count as part of the CCT.”

BOTA feel that Training Programme Directors should be reassured that time spent away from the region will be added on to the end of training with no net loss of time spent locally.

The BMA document ‘Broaden Your Horizons’2 clearly sets out the benefits of such experience, categorising them as: benefit to the developing region, benefit to the NHS and its patients and finally benefit to the doctor.

Most orthopaedic projects in developing nations place major emphasis on teaching and training of the local doctors and healthcare providers as well as providing practical help through provision of equipment and performing surgery. The UK is becoming increasingly ethnically diverse and the skills acquired dealing with different communities will be of value for the NHS. Similarly working in a low resource setting will allow trainees to be better equipped to work in a system increasingly under financial restraint. The benefits to the doctor are multiple and include the acquisition of both ‘hard’ and ‘soft’ skills. There are opportunities to develop teamwork and leadership skills, management skills, ability to cope with change and allocate resources. In particular,

from a surgical training point of view, operating in a context of limited resources necessitates understanding and managing patients on the basis of first principles. This allows for a deeper understanding of why and when surgical techniques are appropriate and an ability to think outside the box with improved problem solving skills as and when required. All these skills are clearly transferable to an NHS setting, meaning that trainees returning from OOPEs in developing countries will be reinvigorated, clinically more able and confident.

As well as the JCST and BMA, the Department of Health are also supportive of collaborative healthcare initiatives with the Framework for NHS Involvement in International Development,3 emphasising the mutual benefit to the NHS and developing region.

Given the broad support for OOPEs from organisations directly involved with training, BOTA have major concerns that some training regions are apparently obstructing trainees from potentially significant opportunities to develop clinically and professionally.

BOTA aim to give practical support to OOPEs through subsidising humanitarian projects and advertising through our website and newsletter. We will fully support any member who is having difficulty in gaining approval to take time out of programme for a humanitarian OOPE.

Summary

BOTA would like to join the Department of Health, BMA and JCST in giving its full support for trainees wishing to undertake an OOPE. The benefits to the trainee, the area of need, the original training programme and ultimately our patients are clear and should be actively encouraged by all training programme directors.

1. http://www.jcst.org/mmc_trainee_info/takingtimeout_html

2. http://bma.org.uk/developing-your-career/career-progression/broaden-your-horizons

3. http://www.thet.org/health-partnership-scheme/resources/publications/the-framework-for-nhs-involvement-in-international-development

Humanitarian ‘Out of Programme Experience’ BOTA Position Statement

Gerard Cousins

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Educational Weekend

BOTA Educational Weekend 2014 38-39

Picture Gallery 40-43

BOTA Trainer of the Year (TOTY) 2014 44

Trainer of the Year 2014 Winner – Peter Bates 45

Trainer of the Year 2014 Runner-up – Niall Eames 46

Trainer of the Year 2014 Runner-up – Christopher Kershaw 47

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BOTA Educational Weekend 2014Mustafa Rashid

Educational Report

It has been a great pleasure being on the BOTA committee for another year. The Education Rep position is a busy one with a roaring crescendo leading up to the BOTA Educational Weekend. Throughout the year I have attended the Training Standards Committee (TSC) meeting at the BOA offices. This committee, chaired by Professor Phil Turner, is tasked with dealing with curriculum issues and the discussions this year have focused on a variety of topics ranging from workplace-based assessments, the introduction of the new-style learning agreements, the new generic PBA (the GOSLE) undergoing validation, and the fine-tuning of the new simulation curriculum (introduced in August 2014). The issue of training in Major Trauma Centres (MTCs) was also discussed at the TSC and we heard a balanced argument for and against training in MTCs however it was clear that there was great variability in the quality of training on offer.

The Education rep also sits on the BOA Education Committee, which is responsible for the delivery of the curriculum set out by the TSC. Issues that arose in these meeting during my term were: the new BOA Undergraduate project, Wikipaedics (formerly Orthoteers), and re-structuring of the BOA Instructional Course for January 2015, which looks like a great programme and an event I would highly recommend.

The BOTA Educational Weekend 2014

The Educational Weekend 2014 in Carden Park, Cheshire was a tremendous success this year mainly due to the hard work and commitment of this year’s BOTA committee and our events organiser, Sue Dale. This year we managed to secure a record amount of funding from industry sponsors who have been incredibly supportive as ever. The 2014 meeting saw BOTA’s first Diamond Sponsor, DepuySynthes, to whom we are extremely grateful for their support. All Diamond, Platinum and Gold sponsors held outstanding workshops with great content. Special recognition must go to Heraeus, winners of our “Best Industry Workshop 2014” award for their workshop entitled “What YOUR examiner needs to know” held by Mr Jason Webb and Mr Mike Whitehouse.

Day One

I was extremely fortunate to be able to put together such an incredibly strong faculty that did not disappoint. Each speaker gave engaging, insightful and educational talks that met the learning needs of our BOTA delegates. Professor Andrew Carr from Oxford kicked us off with a very insightful and interesting talk on “Translational Research in Orthopaedics”. He covered many interesting topics including; Evidence-based Surgery, the role of Registry data and level 1 evidence in Orthopaedics. Prof Carr also gave us some awareness of how implants are regulated and evaluated in the UK and the rest of the world.

The Friday morning session was focused on Orthopaedic Research and the Glenohumeral joint. Mr Steve Corbett from London gave the next talk covering important aspects of decision-making in treating proximal humeral fractures, an area where our pre-conceived ideas of how these should best be treated are currently being challenged with the impending results of the ProFHER trial. To finish off the morning session Professor Matthew Costa from Warwick shared his experience on conducting a clinical trial in Orthopaedic surgery. Many of you are

aware that his team in Warwick are spear-heading several multi-centre clinical trials in the UK, having recently published the DRAFFT trial. Prof Costa told us about the challenges he personally faced as well as how “being hated” for publishing your results may naturally occur, a phenomenon I had not considered!

During the short coffee break it was great to see BOTA members making the most of our record Industry Sponsorship. Delegates also had the opportunity to view the poster displays during this break. There was an incredibly high standard of research on a wide variety of topics from all over the UK, many submitted by junior members. Two more lectures followed prior to the lunch break. Professor Roger Emery from London gave us a whistle-stop tour of the management of Glenohumeral OA followed by arguably the best talk of the weekend from Mr Peter Bates, a trauma surgeon from the Royal London Hospital. Mr Bates’ great enthusiasm and expert tips for achieving

that “glorious reduction” was incredibly well received. He covered lower limb trauma and each sentence seemed to contain yet another pearl of wisdom for achieving a better outcome for our complex trauma patients. This talk also revealed to our BOTA members, whom have not had the privilege of being

trained by Mr Bates, why he was shortlisted for BOTA’s Trainer of the Year 2014.

Carden Park is a great facility for our Educational Weekend as it blends so many desirable factors. We were able to use the excellent break-out rooms for the Industry-sponsored workshops which this year had been moved to the middle of the day on Friday. We were fortunate to have such high quality workshops from DepuySynthes, Heraeus, Orthofix, Stryker, X-Bolt and Zimmer. Another first for this event was our first non-Orthopaedic Industry workshop, by Hodgson Solutions Ltd whom attracted popular attention on their seminar covering various financially-related advisory topics tailored for Orthopaedic Surgeons.

The Friday afternoon session focused on the hip joint with two eminent speakers from Exeter and Bristol, Mr John Timperley and Professor Ashley Blom. Mr Timperley started the afternoon talks with a great lecture on the pitfalls of hip surgery. He put his own slant on this, making it more a series of useful tips for trainees to consider when setting up their own arthroplasty practice as consultants. His useful advice on collecting your own outcome data and some information about how Professor Briggs’ GIRFT report may affect revision hip surgery in the future provided trainees with more food for thought. Professor Blom continued the session with yet another talk of exceptional standard discussing how to deal with the infected arthroplasty. He covered many topics starting from the factors leading to infected prostheses to newer strategies in infection prevention.

To conclude the Friday we included a new session for the three highest scored academic abstracts. These three abstracts were invited to present their work as a 5-minute podium presentation followed by questions from the audience. Members of the audience scored the presentations using the Audience Response System (ARS). The ARS was employed throughout the Educational Weekend as a new addition to enhance the delegate experience. Ben Dean, a DPhil candidate from Oxford currently undertaking an OOPR, triumphed with his abstract: “The neurohistology of painful and pain-free tendons.” The final act of the day was to give out the remaining prizes including Industry workshop of the year (Heraeus) and several prizes for the delegate quiz. Full weekend delegates then made the most of the BBQ and bar facilities before a sensible and civilised conclusion to the first day of the Educational Weekend.

“This year we managed to secure a record amount of funding from industry sponsors who have been incredibly supportive as ever”

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Day Two

The Saturday of the Educational Weekend has traditionally been made up of lectures attended by a diminished crowd of hungover BOTA members! This year however saw a great turnout, in no small part due to the excellent faculty that continued the trend of outstanding talks. In addition, the new Consultant-led workshop session followed the talks providing delegates of all levels the opportunity for small-group interaction and learning. Professor Phil Turner, an experienced knee surgeon from Manchester as well as previous North Western Deanery Training Programme Director (TPD) and Chair of the BOA Training Standards Committee, gave an excellent talk on how trainees can make the most complex of Total Knee Arthoplasty simpler to deal with. His approach of considering what aspects of the knee are missing was very useful to many trainees of varying levels. Professor Turner covered pre-operative planning, instrumentation, and gave eager delegates a strategy and top tips for these complex cases.

Two more speakers, both from Wrightington, finished off the morning session covering Sports Injuries in the Athlete’s shoulder and Fracture Dislocations of the Elbow by Professors Len Funk and Adam Watts respectively. They gave us a glimpse into these difficult injuries and how they are best managed. BOTA members wishing to learn from the experts were not disappointed as Professors Funk and Watts draw on their unique practices to give us useful tips for management and rehabilitation of these injuries

There was something for everyone on Saturday late morning, whether you attended the Educational weekend for the first time as a junior member or a seasoned veteran looking to gear up for impending Consultant interviews. This new session enabled BOTA to reach out and put on a workshop for all learning needs. Pete Bates continued his fine form with a practical session on the use of Poller screws in intramedullary nailing. Mr Sanjay Anand and Professor Simon Donell covered difficult topics for the FRCS (Basic Science of Articular Cartilage and Patellofemoral OA), and Mr David Clark ran our first ever Consultant Interview seminar with our very own Past President, Mr David Machin (newly-appointed Consultant at Mid Cheshire NHS Hospitals Trust). This session was well attended by our senior trainees and was no doubt a great seminar.

We were blessed with great weather for this year’s Educational Weekend, which made for a great afternoon social programme that included outstanding golf on the Nicklaus course at Carden Park (outstanding in terms of the course layout and condition, not the quality of the golf!), and the ever-competitive Outdoor Team Games which yielded a first-ever “BOTA Duck-herder of the Year” Prize. The black tie dinner kicked off at 7.45pm with a great menu on offer, speeches from the committee, even more prizes, and the unveiling of BOTA’s Trainer of the Year (TOTY).

Day Three

The next morning the BOTA AGM was held and members were updated of the organisation’s financial situation, current hot topics in training and what the future holds for Orthopaedic trainees in the UK. The TPD forum followed, which was attended by several TPDs and by Mr David Large (SAC Chair). The first issue discussed was that of Learning agreements and AES/CS roles. We heard how certain deaneries allocate AES for the whole length of training whilst others allow the CS and AES to be the same trainer. The latest round of National Recruitment where the cut-off mark for the clinical station was fervently discussed in addition to the increase in NTNs for 2014 (up to 193). TPDs and delegates raised concerns about meeting the demand for more Orthopaedic Consultants versus the financial restrictions of increasing Consultant numbers to meet the increase in NTNs. Overall the TPD forum provided a great platform for trainees and TPDs to discuss burning issues and to gain further awareness of how different regions are meeting these challenges.

The final section of the Educational Weekend was to elect the incoming committee and it was great to see such enthusiasm for new members to get involved. Each post was hotly contested with close voting in all categories especially for Junior Representative which saw a glimpse of what an Orthopaedic boy band would look like, “Another Direction” or “Lag That” perhaps, as five keen junior members stood alongside each other to deliver their manifesto. Needless to say, the members elected all showed great enthusiasm to work hard and commit to BOTA and the work that is done to represent our members at every level of training.

I would like to personally thank the whole committee, Sue Dale (BOTA Events Organiser), all the Industry sponsors, the consultants, and delegates that made the 2014 BOTA Educational Weekend a roaring success and I welcome Simon Fleming, the incoming Educational Representative to the role which has provided me with great opportunities to meet and represent BOTA members during my year as Education Rep.

“Prof Costa told us about the challenges he personally faced as well as how “being hated” for publishing your results may naturally occur, a phenomenon I had not considered!”

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British Orthopaedic Trainees Association

Educational Weekend 19- 21st June 2015

Highlights FRCS workshops

Practical workshops

Key lectures from an exceptional faculty

Poster presentations and prizes

Annual TPD forum

BOTA AGM and committee elections

Golf Tournament

“Mud, sweat & gears”

Children’s Crèche, Spa and Gym access

This is one of the highlights of the year at the BOTA educational weekend. It is our way of thanking the very best trainers from around the country. We are an organisation for British orthopaedic trainees but without excellent consultant trainers and colleagues to coach, mentor and aspire we wouldn’t be able to maintain the highest standard of surgical care we all strive to achieve. There were 22 nominations from across the UK and it was a real shame we could not get every region to submit their regional Trainer of the Year nominations, as I am sure each region has excellent trainers they can nominate. To highlight the high calibre of trainers nationally all the committee members, linkmen, SAC and the BOA educational advisor scored the nominations. This enabled a wider audience to hear the fantastic stories of great training occurring around the country.

The top three ranked trainers of the year were Mr Peter Bates from the North East Thames-Royal London Rotation, Mr Niall Eames from Northern Ireland Rotation and Mr Christopher Kershaw from East Midlands South Rotation. All three candidates had fantastic nominations making it exceptionally hard to choose between them, however Mr Peter Bates won and gave an inspiring acceptance speech at the weekend.

BOTA Trainer of the Year (TOTY) 2014Peter Smitham

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Why should they become TOTY?

Following a unanimous vote across the rotation, I am delighted to nominate him as BOTA TOTY. From the moment you walk into the trauma meeting on a Monday morning to the last sip of the beer ‘reflecting’ on the Friday trauma list he oozes teaching passion.

He revolutionized the trauma meeting from a business meeting to an enjoyable balance of clinical teaching, operative planning with a healthy contribution of exam relevant literature and ‘hot off the press’ techniques. He leads by example, creating a supportive environment for trainee development across all levels and abilities. Praise is openly given where deserved and where expectations are not reached they are supported to improve.

He makes coming to work enjoyable. Whether his sense of humour, down-to-earth professionalism, satisfaction knowing that you performed a difficult case you never thought was within your surgical ability, or getting the best outcome from a difficult group of patients, you get motivation and confidence from being part of his team.

He has an overwhelming ability to teach the most tedious topics of basic science so even the most academically ungifted trainees understand them! He takes the lead in rotation teaching and has been instrumental in setting up teaching courses on trauma, basic science and practical orthopaedics to junior doctors.

Putting into words how much trainees want the opportunity to work for him it’s the most sought after job on the rotation and region, despite knowing that the three session list regularly extends deep into Friday night beer drinking!

Please give an example of how this trainer manages their theatre lists to enable excellent training.

He ensures that the major trauma centre experience not only gives the trainee the opportunity to see complex trauma but do trauma. From the most complex pelvic and acetabular fracture to a simple MUA he has a wealth of ‘take-home’ tips and tricks to improve a trainee’s surgical ability. His ability to navigate a trainee through a complex case, taking them beyond their perceived ability inspires confidence

in the trainee. He fights the trainees’ corner against the pressure of management for service delivery, the incompetent scrub nurse and the ‘cancel the last case, time to go home’ anaesthetist!

Please give an example of how this trainer manages their clinics to enable outstanding training.

He has an unmatched ability to make every patient a training opportunity. Teaching in an elective setting is easy; maximizing training in an unpredictable clinic of polytrauma patients requires his enthusiasm and natural talent to make the best of whatever is thrown in.

Whether basic science, principles of fracture management or pre-op planning, he makes the opportunity to take your knowledge to the next level. Clinics are a resource comparable to any AO fracture, trauma or basic science course. Trainees having the opportunity to work with him take away an ability to make evidence based decisions on any trauma patient.

In what way is their training and education innovative or how does it “go that extra mile” compared to other trainers in the region?

He is not only a phenomenal individual trainer but from the day he started it was apparent that his contagious enthusiasm to teach has spread across the department to motivate his consultant colleagues. He understands that happy, motivated trainees will work harder and aim higher. He selflessly engages with management to ensure training opportunities are not compromised.

It is clear that he is always aiming to continuously improve both his teaching techniques and the department’s. The improvement in the department’s focus on trainees is evident that not only trainees on rotation are keen to spend as much time here but by reputation trainees on other rotations are keen to transfer in specifically for his hands-on complex trauma apprenticeship.

In comparison to other trainers, he does not view teaching as a “sometime thing” when it suits them or in a specific clinic or session but an “all time thing”.

What would their last few trainees say is the most important thing that they learnt/remember most whilst working with them?

“The drapes only do what you tell them to do.”

“You’re happy with the fracture reduction. He congratulates you, looks hard at the x-ray and suggests a simple manoeuvre and it goes from good to great. This is not cosmetic. The patients in clinic are doing well. The outcome is justified by the methodology.”

“He is very supportive of the juniors in the department. He is an excellent observer picking up those who are in difficulty, speak to them, support them until they progress.”

“Your output and your ability are a reflection of your desire and commitment to achieve excellence.”

“He ensures even the 4th assistant is inspired and involved in his operating theatres.”

“If I’m struggling, he does not take over from me. Instead, he stops me and explains why I am struggling, and then lets me correct it and overcome the struggle.”

Trainer of the Year 2014 Winner – Peter BatesJohn Stammers

“He is not only a phenomenal individual trainer but from the day he started it was apparent that his contagious enthusiasm to teach has spread across the department to motivate his consultant colleagues”

JOINT46


This is the second year in a row he has been nominated for Trainer of the year and the trainees in this deanery are passionate about his recognition. In his role as a Consultant Spinal surgeon within a high volume surgical unit he provides patient care and orthopaedic training of the highest standard. The following highlights a few of his attributes, which make him, a regional training treasure, which are elaborated on under the relevant subsections.

FRCS examiner – trainees are invited into his own home for mock viva and clinical exam. He co-ordinates this with other consultants to ensure every specialty is covered.

Research – founded a local research group in the last 12 months to promote education and research within the deanery.

Education – he has developed a local teaching curriculum for spines in response to the critical case based discussions and CCT requirements. He hosts a spinal journal club.

Technical skill – trainees have exposure to a wide variety of spinal cases from discectomy, thoracotomy, neck dissection, laparotomy and deformity work.

Leadership – he is respected among his peers as a great surgeon. He generates enthusiasm from his trainees and leaves them driven and wanting to see and do more. He has the ability to teach and educate without judgment or humiliation.

Pastoral care – every trainee in this deanery knows that there is someone they can talk to if things go wrong be it professionally or in their personal life.


Pressures on the spinal service within this deanery are increasing. The spinal rota collapsed two years ago and elective operating put on hold. Despite this he pushed for the appointment of two new consultants and a spinal fellow all of which have been achieved, but never once has he let service delivery impede training. The trainee essentially plans his list.

Pre-operatively the trainee will have prepared for the case and presented this to him. After discussing the approach and technicalities of the case the scalpel is handed to the trainee. The trainee will carry out the procedure under his guidance and expertise. His goal is trainee progression. His calm and effortless nature provides an excellent learning environment that puts the trainee at ease. Every case is a training case and he enjoys at the end of an attachment watching the trainee operate independently knowing that he has trained them.


Clinics are frequently over booked but he does not neglect training in this environment. Every patient is discussed and any cases he feels are of benefit to the trainee (with his FRCS hat on) are highlighted and presented in a case based manner. This allows for work-based assessments to be completed in real time in a pleasant and constructive environment. He ensures that the clinics have the correct balance of new referrals and review patients to allow the trainee to experience a wide variety of conditions and their subsequent management.


Within this deanery less emphasis has been placed on academic research and the trainees feel disadvantaged in light of the new CCT requirements. This was brought to his attention and he founded a local Spinal Research Group with a view to promoting education and research amongst trainees. This group has been responsible over the past year for the acceptance of 20 abstracts, 5 papers and the winning of 3 prizes at National Meetings including the podium at Brit Spine 2014.

He has produced a local curriculum for spinal teaching to cover the newly introduced critical case based discussions.

Lastly, he has supported trainees that have experienced personal difficulties over the last year. Inviting them into his home, he has provided support and guidance to a number of trainees in difficulty. Our trainees feel that he is someone to talk to, not just a teacher or a role model…a friend.


“Everyone leaves this post wanting to be a spinal surgeon!!!”

“He makes me want to be a better surgeon… He shows that by going the extra mile in every aspect of life the benefit this can bring to both others and yourself.”

“One day you could be doing a retroperitoneal approach to L4, the next a thoracotomy and while you as the trainee may feel overwhelmed by the complexity of the surgery…he hands you the knife and you are safe in the knowledge that there is nothing he cant get you out of…!”

“He teaches all the facets of becoming a great surgeon…knowledge, technical skill, enthusiasm, compassion, approachability, teamwork, communication, patience and effective leadership.”

“He has found the balance between work and life…trainees come away feeling inspired that one day they want to achieve what he has.”

Trainer of the Year 2014 Runner-up – Niall EamesCiara Stevenson

“He teaches all the facets of becoming a great surgeon…knowledge, technical skill, enthusiasm, compassion, approachability, teamwork, communication, patience and effective leadership”

JOINT 47


Our trainer of the year nomination is an exemplary teacher of the “old school”. He is a past Training Programme Director of this deanery, carrying out the role between 2002 & 2007. As an active member of the SAC, he takes a supportive role in our own ARCP/RITA process as well as being the external representative in other regions.

Trainees attached to him learn humility, patience and the “art” of being a good doctor. He is the sort of person that other consultants turn to for advice. He will openly inform you of mistakes, but also of good performances.

He is a strong advocate of the trainees’ having a say on their consultant trainers and has supported our yearly trainees’ survey that ensures good training does indeed take place.

His name is widely and regularly considered during trainer of the year nominations. He has been voted our Regional Trainer for the Year three times in the last four years and was nominated as runner-up for BOTA Trainer of the Year award in 2010, supporting the event by attending the black tie dinner with his wife Irene.

In conclusion, we feel that our trainer should be voted BOTA’s Trainer of the Year because he always goes that extra mile for trainees. He cares about the trainees. He wants them to succeed, in life as well as orthopaedics. It is all about getting the balance right and we think he is a fine example of someone who has.


In the first few weeks of your time with him, the numbers of cases listed are reduced to accommodate for teaching and familiarization.

Beyond this trainees are both tutored and allowed to practice independently depending on the level of confidence or competency. Nevertheless, he is ever present to provide complete supervision.

A typical example–a senior trainee was short on 1st ray surgery – he spoke to his foot and ankle colleagues so that required cases were transferred to his care. He created 2 theatre lists primarily done to help this trainee gain the necessary logbook numbers.


His clinics are a fantastic learning opportunity for trainees, be it at an FY1 level or ST8 level. His willingness to impart knowledge is evident during his clinics. Clinics are arranged to allow one to one teaching, discussing history, examination and management plans. His practice is based on paediatrics and lower limb including foot and ankle, meaning a broad scope is covered. However, as a specialty placement for orthopaedic paediatrics, his placement is a sought after rotation amongst trainees for these reasons.


This trainer is an examiner for the FRCS Orth, and brings enormous experience when it comes to teaching and preparing trainees.

He has been setting aside Monday or Wednesday evenings for weekly tutorials for those registrars approaching the exams (except around Christmas/ Easter or Annual leave – he needs breaks after all).

This has been on-going for at least five years in the comfort of his own home.

The 100% pass rate in the FRCS exams that we have maintained in the last six years is by no means easy and we have no doubt that his contribution has been instrumental.


Keep learning and improving your practice – even as a senior consultant with only a handful of years to retirement – he is ever willing to change or modify his practice.

The sincerity in his actions.

His dedication to training the next generation.

His willingness to offer timely advice to trainees but also to his consultant colleagues.

His ability to teach and convey concepts is second to none.

By going above and beyond the call of duty when holding FRCS revision at his own home, demonstrates his passion and commitment to his trainees.

His ability to inspire confidence amongst his trainees, in both clinical management and surgical skills.

His down to earth and empathic nature is clearly demonstrated by how happy patients are to be treated by him.

For all these reasons Mr Kershaw was again voted LOTA trainer of the year for 2013.

Trainer of the Year 2014 Runner-up – Christopher KershawReshid Berber

“Trainees attached to him learn humility, patience and the ‘art’ of being a good doctor”

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Reviews

A Brief History of BOTA 50-51

The Orthopaedic Trauma Society (OTS) 52

A Perfect Fit – The Chavasse Report 54-55

Naval Reserves 57

Setting up a Medico-Legal Practice 58-59

Ever Thought of Reviewing Books for the Journals…? 61

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The Final Report of the independent Shape of Training review was published on 29th October 2013. The introduction to the Report emphasises:

“Good medical education is essential to good medical practice… In recent years there have been significant developments in UK medical education and training, following recommendations made in a number of seminal reports. However, those reports have also pointed to the need for further reform if medical education and

training is to support and respond to society’s changing needs. In 2007 the independent inquiry into Modernising Medical Careers, led by Sir John Tooke, made a number of recommendations about the shape and structure of postgraduate medical education and training in the UK. In 2011, Medical Education England (MEE) identified issues facing the future of postgraduate medical training which included: balancing the needs of the service and the demands of training; balance between generalist and specialist care; flexibility and value for money; and the need for innovation set against the risks of de-stabilisation if present arrangements were changed. They agreed that further work on the shape of training was necessary and should be taken forward, led by an independent chair. David Greenaway was appointed in February 2012.”

In his BOA President’s newsletter for March 2014, Professor Tim Briggs advised he had attended a meeting of the Surgical Forum of GB and Ireland to discuss the Shape of Training report. The BMA Representative Body and its Consultants Committee believe the Report’s proposals will not produce consultants with the level of training required by patients, the profession and service. The Junior Members Forum believes the proposals should not be implemented in their current form. Watch this space, closely.

There have long been concerns about training–not simply the ‘shape’ and ‘tensions’ between service needs and training demands as currently emphasised, but about the quality of training itself. As long ago as 1910 the seminal report by Abraham Flexner–Medical Education in the United States and Canada had castigated most medical schools in the US and standards were hardly better in the UK. Even by the 1980’s quality of training was highly variable–with training programmes ranging from being well organised by conscientious committed trainers to those where the ‘pair of hands syndrome’ was all too prevalent.

As soon as I felt relatively fireproof following appointment as consultant orthopaedic surgeon at Bedford Hospital in 1985 I decided to address some of these training issues. I wrote to all of the senior orthopaedic registrars I could identify, noting that “The British Orthopaedic Trainees Association does not exist, but I believe it should! You will be aware of the many problems of training and career structure and you may feel that trainees’ opinions should be coordinated. The president of the Royal College of Surgeons, Sir Geoffrey Slaney has said ‘the College cannot affect everything that happens–it is up to you as individual surgeons to play your part and be involved.’ ”

I pointed out that orthopaedic trainees had no group to represent their specific interests and asked if they would be prepared to attend a working party to further consider the matter. The response to

this initial inquiry was so encouraging that I simply went ahead and organised a weekend meeting, securing much appreciated support from Boots PLC.

On the 12th June 1987 forty-five Senior Registrars, accompanied by their families attended the Inaugural Conference in Oxford. The meeting was entitled ‘Planning a Career in Orthopaedic Surgery’ and included presentations from; Chris Ackroyd (Secretary, BOA); George Bentley (President, BORS); Robert Duthie (Professor of Orthopaedic Surgery, Oxford, Past President, BOA); John Sharrard (Chairman Manpower Advisory Panel, Past President BOA); Philip Fulford (Deputy Editor, JBJS); Tim Archer (President, ASiT) and management academic Stuart Haywood. There was much discussion on the future of orthopaedic training and it was agreed that the British Orthopaedic Trainee Association should be duly created. The draft constitution was agreed and I was elected President; Andrew Jarvis, Secretary and Tim Bunker, Treasurer. In 1988 the officers and committee were re-elected for a second term. In order to provide continuity and to allow young consultants to make contributions free of the reticence which was then necessary in SRs we determined membership would be open to all those on recognised programmes of higher orthopaedic training or within two years of substantive appointment as consultant. Other juniors were welcome as associates. At that time we felt we had quite enough problems of our own without taking on the responsibility for staff and associate specialists but clearly times change and the franchise is now more widely cast.

From the start I tried to secure a wide range of speakers–from the hierarchy of the BOA, orthopaedic professors, BMA, RCS and eminent contributors from non-orthopaedic specialities as well as managers and academics from the laity. An eclectic but stimulating mix and a principle that has by and large been followed since. A particular feature of these weekends was that significant others and children were encouraged to attend and enjoy the facilities of the venues which were chosen with their needs in mind. Most of the letters of thanks we received were from wives, many of whom remarked how much they appreciated meeting others away from a macho competitive environment. A commonly expressed feeling was that “Until this meeting I did not realise that other trainees had the same problems as my husband”. In those days there were few lady members, though Debbie Eastwood was to become Secretary in short order and Clare Marx is now President of the RCS.

One of BOTA’s first forays into the politics of training was to carry out a questionnaire of trainees: ‘A Pilot Survey of training programmes: A review of the methods by which training programmes are assessed’. This was presented as a poster to the BOA meeting held in 1988. Such a review appeared never to have been attempted before, though now feedback to the BOA and Postgraduate Deans is a regular feature of a trainee’s experience. Our findings and presentation stimulated much discussion, some of which was constructive. The results were confidential–suffice it to say there was a wide discrepancy in the perceived value of various training programmes, and trainers. Some important topics were adjudged adequately covered in only 25% of programmes. Many trainers were described as excellent. Many were deemed to be less so, including one who had climbed out of a ground floor window in order to avoid being seen by patients as he left the NHS out-patient clinic early to attend to others in the private wing.

Through the auspices of BOTA I then requested copies of the submissions made by each training programme when seeking recognition by the Surgical Advisory Committee. A number of programme chiefs replied promptly. Some did not reply at all. Having gained access to the relevant information by other means, it became clear that a number of chiefs had been ‘economical with the truth’ in

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their applications. It was no surprise to note the association between the accuracy of information in the application and the trainees’ opinions of the quality of their programmes. In all events the BOA took the issues on board and invited Tim Bunker to join its Council when he became President after my own second term.

The poster for the 1988 BOA meeting also presented some thoughts on The Future: “Members of BOTA are acutely aware of the rapid changes taking place in so many aspects of British Medicine. ‘Achieving a Balance’ will significantly change the careers to which they have aspired. Cash limits, and other management issues will require a change in emphasis during training. The FRCS examination itself is undergoing changes. Our own survey has indicated weaknesses in many current training programmes and in respect of many current trainers. BOTA hopes to identify these and other important issues and to give appropriate consideration to them. This process will not only widen debate but also in itself act as an education and training for members.” Could have been written today!

From the start BOTA has always sought to be constructive and in order to encourage trainers we instituted the ‘Trainer of the Year Award’–chosen by a consensus of BOTA members. The first recipient in 1989 was Chris Colton–who had the temerity of presenting a talk at one trainees meeting not only in a roll neck jumper without a tie, but with a medallion around his neck! Whatever next–scrub suits in the clinic?

In 1990 we met in Cambridge to discuss ‘Assessment of trainers and trainees in the 90’s’. Speakers included ‘Trainer of the Year’ Hugh Phillips but Labour MP Dr Sam Galbraith was unable to attend as he was due a heart-lung transplant for fibrosing-alveolitis–the most dramatic ‘apology for absence’ I have encountered! The operation was successful.

The days have largely passed when medicine was practiced in an anachronistic atmosphere of paternalism–‘doctor knows best’. Patients now expect to be given all the information they need about proposed treatment in order they can give meaningful consent in a spirit of collaboration and mutual respect. Automatic deference to authority by trainees is becoming passé and accountability of trainers in a collaborative atmosphere of intellectual, educational and professional goodwill is now the byword. Those trends should continue but the vigilance of trainees will still be necessary, together with the cloak of confidence provided by your own professional association. Vivat BOTA!

“The BMA Representative Body and its Consultants Committee believe the Report’s proposals will not produce consultants with the level of training required by patients, the profession and service”

JOINT52

The concept of a British Orthopaedic Trauma Society (OTS) was born about nine years ago. It finally came to fruition when a group of British orthopaedic trauma surgeons had a lunchtime discussion at the annual American Orthopaedic Trauma Association meeting in Minneapolis in October 2012. Nigel Rossiter, the most senior member of the group, was nominated as the first President. He has been supported by a committee of 15 trauma surgeons from around the British Isles based at both Major Trauma Centres and Trauma Units.

The OTS committee is formed by the following group of surgeons. Their roles are listed below:

The American Orthopaedic Trauma Association started in 1977. They recall how useful their early meetings were, and how the association served as an invaluable forum for the trauma surgeon. Many were able to share viewpoints and collaborate on the cutting edge of trauma for the first time. We hope the OTS will grow into a similarly successful society, not only organising meetings but co-ordinating and collaborating on trauma research, education, fellowships and training. We endeavour to advance the practice of excellence in orthopaedic trauma in the British Isles.

We launched the OTS in August 2013 at the Edinburgh Trauma Symposium with a research meeting on August 20th. There were 25 excellent papers presented from both British and international hospitals. The society will hold a research meeting for the presentation of original research in conjunction with the Edinburgh Trauma Symposium in August each year. This is a day set aside for presentation of papers and posters. Six of the best submitted papers are selected for presentation during the symposium to an international audience, and they may also be asked to present during our annual meeting.

Education is an important part of the society and Mike Kelly is the lead for this. We first held sessions at the British Orthopaedic Association meeting in Birmingham in October 2013. Both the instructional course and ‘boot camp’ sessions were well attended, well received and often over subscribed. These were useful for both the trauma surgeon and the elective orthopaedic surgeon still on the oncall rota and needing to update and revalidate in trauma.

Mike with his team organised another outstanding trauma boot camp at the BOA/EFORT meeting in June this year. This is the third such “Trauma Bootcamp / Trauma Update” the OTS has organised at national and international meetings with growing outstanding acclaim. We hope that this will carry on and continue to aid revalidation for consultants and education for trainees. We will be holding two sessions at the BOA meeting in Brighton on Friday 12th September 2014: a session on “Fracture Clinic Re-design”, and a debate on: “This house believes that all patients who have an intra-capsular fracture, displaced or otherwise, and are of an age who could receive an arthroplasty should receive one rather than reduction and fixation”.

We held our first official OTS meeting at The Royal College of Surgeons in March this year. This concentrated on the planning of collaborative research in orthopaedic trauma in the British Isles.

Our annual OTS meeting will take place in March annually and is likely to rotate around venues within the British Isles. The next meeting will be in Warwick from 19-20th March 2015, with the National Institute for Health Clinical Trials day on 18th March 2015. The format will be the trials day presenting results of our national studies and plans for new studies on the Wednesday; OTS meeting on the Thursday and Friday including updates, topics for debate, best of the best papers, guest lecture, industry symposia, practical sessions, issues around service delivery, a ‘Tips and Tricks’ session, results from major trials, and a Dragon’s Den for new research proposals.

Trainees may be interested to hear that Daren Forward and Mark Jackson are setting up a database of fellowships opportunities within the UK which will appear on the OTS website. The aim is to allow a potential fellow to go onto the website, see what is available where, when, with whom and, whom to contact.

We would like to extend an invitation to all trainees with an interest in trauma to join the OTS.

For more information go to http://www.orthopaedictrauma.org.uk

The Orthopaedic Trauma Society (OTS)Charlotte Lewis

Executive Committee

President Nigel Rossiter

President Elect Bob Handley

Treasurer Andy Gray

Secretary Charlotte Lewis

Education Mike Kelly

Committee

Research Matt Costa & Ben Ollivere

Fellowships Daren Forward & Mark Jackson

Liaison Bob Handley

Membership David Noyes

Meetings Tim White

Public Relations Nick Hancock

Website Paul Jenkins

Policies Paul Fearon

BOA Trauma Group Representative

Tim Chesser

BOA Training Standards Committee Representative

Paul Fearon

“We endeavour to advance the practice of excellence in orthopaedic trauma”

Orthopaedic and trauma experts are more and more confronted with increasing medical complexity accompanied by incisive economic limitations such as tight budgets and time pressure. An interdisciplinary educational approach provides prospective Ortho paedic and Trauma surgeons with the overall comprehension required for a successful patient’s outcome considering this trend both in primary and in revision arthroplasty.

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Practice oriented interdisciplinary formatsThe Heraeus PALACADEMY® educational programme offers a broad spectrum of workshops and courses in the fields of arthroplasty for orthopaedic and trauma surgeons at different levels of experience. Interdisciplinary faculties, interactive group discussions, and handson sessions allow for a high practical relevance of the acquired knowledge and facilitate peertopeerexchange amongst the healthcare professionals. A range of training courses is offered both online as well as live at numerous international events.

To ensure a successful patient’s outcome within arthroplasty, the close interdisciplinary collaboration has shown to be very effective: As infections remain a big challenge, the didactical concept of the PALACADEMY® courses sets a high focus on the interdisciplinary exchange between experts in the fields of microbiology and orthopedic surgery.

PALACADEMY® online – Learning with individual focusInteractive and multimedia learning completes the concept of PALACADEMY®. Registered users benefit from equal access to lectures of both course levels (basic and advanced) to extend their own level of experience, regardless their profession or competencies.

Local instructional courses PALACADEMY® instructional courses are surgeonled and have been developed by international experts from both clinical and research backgrounds. “The courses have been designed to cover the essential aspects of modern primary total hip and knee replace ment surgery, as well as the fundamentals of

PALACADEMY® – Effective Modern Learning revision surgery, with the emphasis on revision for infection. The content has been de veloped to encompass the requirements of the orthopaedic curriculum for ST 3 entry level and the competency expected at levels ST 7 – 8”, says Professor David H. Sochart, North Manchester General Hospital and Salford University and PALACADEMY® Expert.

iPad App “Essentials in Diagnostics of Periprosthetic Joint Infection (PJI)”Prosthetic joint infection (PJI) is a severe complication in arthroplasty and has significant impact on patient’s well-being and healthcare systems. One of the greatest challenges in managing PJI is the “culture negative” prosthetic joint infection. In published case series, the reported rate of culture-negative PJI ranges from 5–41 %. A number of factors contribute to the failure of microbiological cultures to isolate a pathogen.

With the PALACADEMY® iPad App “Essentials in Diagnostics of Peri prosthetic Joint Infection (PJI)” Heraeus Medical provides an educational tool to learn about the challenges and how to improve the diagnostic outcome.

www.heraeus-palacademy.com

Main topics of PALACADEMY®: Preoperative planning and surgical approaches Bone cement properties and modern cementing

techniques Cementing workshops Discussion of case studies & pitfalls in primary and

revision arthroplasty Diagnostics, prevention & treatment of periprosthetic

joint infections

Key features of the iPad app: Cases: stepbystep along with a real case through the

diagnostic algorithm Challenges: most frequent questions and problems

around PJI, practical tips, Videos Media Library: commented literature review, graphs

and figures for download Case Reports: clinical cases for exchange

Druckformat: 210x297 mm Druckfarben: Cyan Yellow Schwarz

06294_Advertorial_BOTA_Yearbook_2014_20140825_RZ.indd 1 25.08.14 17:20

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In the centenary year of the start of World War I all those who have served or are still serving in the armed forces hold a special place in our hearts and minds. Their contribution to the nation is rightly recognised by the UK Government through the Ministry of Defence in the Armed Forces Covenant. Many have health conditions as a direct consequence of their time in military service and the Department of Health, through NHS England, ensures awareness

of and alertness to their needs through the Armed Forces Health Strategy. Similar arrangements apply in the Devolved Nations.

The Chavasse Report is named after Captain Noel Chavasse VC and Bar, MC who died of his wounds in World War 1 at the Battle of Passchendaele and whose selfless heroism saved the lives of many soldiers. The report highlights critical pathway problems for musculoskeletal injuries that account for 60% of discharges from the armed forces: importantly the report also identifies that the key to success lies in effective provision through affordable and sustainable solutions that should enable early adoption by commissioners of care to the benefit of all patients.

The Armed Forces Covenant

The Armed Forces Covenant sets out the relationship between the nation, the government and the armed forces. It recognises that the whole nation has a moral obligation to members of the armed forces and their families, and it establishes how they should expect to be treated, including their health needs. For more detail please see: https://www.gov.uk/the-armed-forces-covenant

The NHS England Armed Forces Health Strategy

The Strategy seeks to enact the Covenant, as envisaged by the NHS Constitution, through a set of core values centred on patients, proactivity, evidence based decisions, ease of access to care, and special consideration for the injured. These are supported by four delivery objectives: commissioning the best health outcomes; strong high level partnership working with the Defence Medical Service to align the NHS system accordingly; effective integration between the military and CCG communities to improve continuity of care for leavers; all supported by embedded, strong, patient centred Armed Forces networks.

To enable rapid progress the Strategy also identifies four priority interventions: harnessing the digital revolution to deliver better care; co-ordinated access to the musculoskeletal pathway; improved access to mental health services; agreed health plans that will empower all leavers to take control of their long term care. Last but by no means least, the Strategy sets out a governance structure that will be essential to ensure appropriate co-ordination, progress and longer term sustainability.

Strategies in the Devolved Nations

For Scotland the Scottish Government Commitments for Armed Forces and Veterans set out arrangements to ensure no disadvantage there – for further detail please see: http://www.scotland.gov.uk/Topics/Health/Services/Armed-Forces

For Wales the Welsh Assembly Government has formulated a package of public service measures:

http://wales.gov.uk/topics/people-and-communities/safety/armedforces/?lang=en.

Due to different legislation in Northern Ireland, which aims to ensure that one population is not advantaged over another, there are currently no supporting documents to the Armed Forces Covenant available. However, work is being carried out with the Northern Ireland Executive and Local Government with the aim of removing disadvantage for Army families within Northern Ireland. Considerable progress is being made at a local level in the areas of education and healthcare.

The Chavasse Report

Chavasse highlights areas where the system can and should do more for the injured in England especially. The report’s guiding principle is to provide solutions that will help commissioners to ensure better and greater continuity of care for those severely wounded in action, injured in training, or suffering debilitating musculoskeletal infirmity as a consequence of their military service (US research shows an increased incidence of osteoarthritis in military personnel). The intention is not to confer advantage on the individuals concerned, rather to ensure that they receive prioritised care applicable to their particular circumstances and contribution.

Chavasse identifies a range of provision solutions to deliver effective management of these conditions. The premise here is that only when provision is correctly configured will CCGs be able to commission appropriate and effective care.

Foremost among the proposed solutions are:

Accelerated referral to treatment times of six weeks for serving and reserve personnel. These times apply to musculoskeletal conditions that are unrelated to training injuries or require specialist services. The six-week period minimises disruption to the wider NHS while according appropriate priority to those serving in defence of the nation.

Accelerated referral to treatment times for veterans of 12 weeks in recognition of their contribution to the defence of the nation. The precise length of time will be determined by the origin of the MSK condition (for example an injury incurred in training or on operations) and the urgency of need.

The creation of a network of NHS hospitals specifically accredited for this purpose and which will be readily identifiable as a consequence of the parallel programme of work, Getting It Right First Time (see http://www.gettingitrightfirsttime.com/).

The creation of a number of NHS Veteran Rehabilitation Units linked to those within the military. In addition to catering for musculoskeletal rehabilitation the Units would also apply a holistic approach to encompass mental health and chronic pain, ensuring a seamless transition of care and shared learning between the Defence Medical Service and the NHS. The Units will also be accessed by ordinary NHS patients as well as veterans, providing a more consistent approach and a step change in NHS rehabilitation services.

The Veteran Rehabilitation Units could initially be jointly funded by the third sector and the Government (from the LIBOR fine).

While Chavasse took the Armed Forces Covenant as its starting point, it is fully consistent with the values and objectives of NHS England’s Armed Forces Health Strategy: as a core component of the musculoskeletal pathway intervention it provides a template and mechanism with which to achieve rapid progress to the benefit of patients. Chavasse also complements the other interventions in

A Perfect FitTim Briggs

The Chavasse Report, the Armed Forces Covenant, the Armed Forces Health Strategy in England and the Devolved Nations

the Strategy: notably mental health where expeditious treatment of musculoskeletal disorders has a direct and positive bearing on patient parity of esteem (in alignment with the Mental Health Concordat: https://www.gov.uk/government/publications/mental-health-crisis-care-agreement); and agreed personal health plans for patients.

Chavasse covers three categories of musculoskeletal patient: members of the armed forces discharged to the NHS, reservists and veterans. Each presents a separate healthcare need for commissioners to plan in view of the accelerated referral to treatment times identified:

In the financial year 2012/13, 2,315 individuals were medically discharged to the NHS, with musculoskeletal conditions accounting for 0% of cases (1,380). In these instances the Defence Medical Service is best placed to refer the individuals concerned directly to secondary care at the point of transfer.

Figures are not currently available for the percentage of the Reservist population likely to be unfit due to musculoskeletal disorders.

Although records have been created for them on the Defence Medical Information Capability programme, the medical assessments of reservists following call up have yet to be captured. Given that there are currently some 30,000 Reservists, and

based on the regular forces experience of 8-10% downgraded at any one time, it is estimated that up to 3,000 individuals may be affected. Engagement with SaBRE (Supporting Britain’s Reserves and Employers http://www.sabre.mod.uk/) will be important here.

With some 4.8 million people in the UK categorised as veterans, a pragmatic approach will be essential. Priority will need to be accorded to those pensioned out of the forces with a specific injury as a proven consequence of operations or training activity (currently numbering around 170,000). Of interest, in the 12 months to 31 December 2012, the overall outflow from the UK Regular Forces was 25,140. This included 4,850 personnel who left under the Armed Forces Redundancy Programme.

The Chavasse Report was launched on the 1st July at the Royal College of Surgeons, England. The reports can be downloaded at http://thechavassereport.com/. I commend it to you all.

BASK ANNUAL SPRING MEETING10th-11th March 2015

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• Medicolegal / Negligence Trial• NJR• Free papers

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JOINT 57

I never met my merchant seaman Grandfather ‘Jack’ Rourke, but I blame him almost entirely for my interest in the Royal Navy. At medical school I was briefly a private in the Territorial Army before placements made it impossible to continue training. And, whilst I enjoyed the physical challenge, there was always something missing. I went on to approach the regular Royal Navy, passed the Admiralty Interview Board and even made it through the Royal Marines officer selection process. My aim at this point was to be a commando trained Medical Officer. However the early years of the century were a bad time for the Royal Navy Medical Service and most surgeons had left, although this is not the case now. As a keen aspiring surgeon I was advised to leave the regular service and get through surgical training. I shelved any military ambition at this point.

In 2006 I returned to Liverpool entirely accidentally as an SpR. Perhaps it was the salt air, the Mersey Ferry, the sheer irrepressible maritime feel to the place. Or maybe it was my father’s stories of my grandfather working as a gateman in Gladstone dock: the home of the 2nd support group fleet and the command of Captain Johnnie Walker. Walker is a local hero, U-boat killer supreme and one of only three Officers to ever hoist ‘The General Chase,’ the other two being Nelson and Drake (Walker’s still hangs proudly in Bootle Town Hall). Either way I found myself drawn back towards the Royal Navy, but this time The Royal Naval Reserve, specifically HMS Eaglet the Liverpool RNR unit. Once I had made the decision to join I was typically impatient and managed to complete initial Officer Training in just a few months. This involved several compulsory weekends covering a similar syllabus to regular Naval Officers in their first term at Naval College, including field craft and survival, boat skills and of course drill i.e. the finer points of marching, saluting and maintaining military bearing. I was delighted to attend the imposing but beautiful Britannia Royal Naval College (BRNC) in Dartmouth in October 2009. Here I was expected to attend lectures, pass fitness tests, march, learn how to host a guest at a dinner and spend three days soaking wet in the field all with urgency, humour and a smile on my face. I turned right off the drill square two weeks later as Surgeon Lieutenant Commander Rourke RNR walking through the front entrance which was previously off limits to officer cadets.

The dreaded exam (FRCS) was six months later, and in hindsight BRNC was the perfect antidote to the pain about to come. In July 2010 I volunteered for initial staff officer training at the military’s University at Shrivenham. Whilst there I received an urgent call asking me if I wanted to deploy to Afghanistan at three months notice as the Orthopaedic SpR. At this point I have to be honest and say that I had not really expected to be deployed so soon. Unlike a lot of medical reserves it had not been my primary motivation in joining and I was about to go on fellowships. However I did feel a distinct sense of duty, and despite the difficulties I agreed immediately. In October I mobilised, learnt to shoot a rifle (badly) and attended the Military Operational Surgical Training course (MOST) at RCS England (probably the best and most timely course I have ever attended). It is designed to train up those Surgeons about to deploy and is totally contemporary with the current threat. I also attended a hospital simulation facility (Hospex) and met all the staff I would be working with in Afghanistan in a fully functioning model of the Camp Bastion hospital. On Christmas Eve I arrived ‘in theatre’ (of war). It remains the most moving and fun Christmas I have ever spent. We had Christmas dinner served by senior Officers, sang carols and called home. It was all terribly jolly until on 27th December our troops went back out on patrol outside of their bases and I saw my first Improvised Explosive Device (IED) injury. It never really stopped after that. We have all heard of the exceptional care at Bastion and the devastating injuries and I won’t labour the point. I worked incredibly hard, fell asleep stood up three times and saw some terrible things, but there was life beyond it. In rare downtime we drank coffee with the Danish, walked

bomb disposal dogs and laughed in a way that only people who have ever experienced that kind of close team environment could really understand.

I got back at the end of February 2011 and immediately flew to Gibraltar and thence to Soto Grande to indulge another new skill the Naval has made possible: riding (specifically polo). I had never ridden before but a ‘dare’ from a cavalry officer found me on horseback swinging at balls at ludicrous speeds. Due to fellowships I have lost a few seasons since but now play for the Royal Navy at Tidworth Polo club. Navy polo has taken me to South Africa and Argentina and I can honestly say has changed my life. One day I hope to play for The Navy vs The Army in the Rundle cup.

I have just finished a very busy year with the RNR and HMS Eaglet. I have trained junior Officers, rescued sinking duck boats, written staff papers for senior Officers, been visit liaison Officer for a visiting Russian ship and the Russian Ambassador, represented the RNR Medical branch at Admiral briefing boards and also found time to keep up my medical skills with an underwater medicine course. I am lucky: my Trust is incredibly supportive. However, within my Trust I have implemented valuable lessons from Camp Bastion in our trauma protocols and resuscitation so they perceive real advantage to supporting my service. Unlike a regular as a reservist I could have turned down any of the above but I generally find I do not want to. Whenever the Navy have placed a door in front of me I have invariably found it worth opening.

I recently returned from my first period of sea time on our hospital ship RFA Argus. She is an incredible facility with a CT scanner, two theatre tables and an ITU/HDU as well as two helicopter pads. Very much a mobile field hospital she could steam anywhere in the world within weeks. Understand though that her greatest asset remains the medical staff she carries. All of them highly trained, enthusiastic and able to cope with adversity to deliver the highest standard of care afloat, all with a healthy sense of humour. It is a different way to live your life but a decision I have never regretted.

To find out more visit www.royalnavy.mod.uk/navyreserves or call 0845 600 3222.

Naval Reserves Asclepius with Poseidon (part-time)

Harry Rourke

“It was all terribly jolly until on 27th December our troops went back out on patrol outside of their bases and I saw my first Improvised Explosive Device (IED) injury. It never really stopped after that”

call 0800 146 307

email [email protected]

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JOINT58

In 2014 newly appointed consultants have different challenges in setting up a medico-legal practice compared to the situation that existed twenty years ago. The landscape has changed significantly with the arrival of medical agencies who act as intermediaries between solicitors and experts, the Woolf reforms introduced in 1999 to try to speed up and reduce the adversarial nature of the claims process and more recently, in 2013, the Jackson reforms which again seek to improve efficiency and

reduce costs and prescribe strict timetables which must be adhered to by experts or the claim may be struck out. Failure to meet these pre-agreed timetables for submission of expert evidence may result in the expert being sued if the case is struck out.

Are you an expert?

It is assumed that if you have been through a recognised training programme in orthopaedics in general and your sub-speciality interest that you possess a level of competence that allows you to practice independently in your speciality. Does that make you an expert in the eyes of the Court? An expert is defined as “someone who has comprehensive knowledge, skill or experience in a particular field.” It would generally be accepted that having gone through a recognised training programme and having been appointed to a “substantive career position” (I phrase that with care conscious that non-consultant career grade doctors carry out expert witness work), it would be reasonable for you to give expert opinions in personal injury cases on matters within your area/s of expertise.

It goes without saying that you should really confine yourself to your own area and should not be giving opinions on issues that would be more appropriately opined upon by other specialists e.g. plastic/vascular surgeons or pain specialists/rheumatologists. Even within the field of orthopaedics, care and selectivity is necessary. A recent article in the BMJ entitled, “Tribunal suspends doctor for acting as expert witness beyond his competence” is apposite (Dyer : BMJ 2014 ; 348 : g4126). It concerns a Psychiatrist who clearly gave an opinion on a matter of general adult psychiatry when his area of practice (and presumably expertise) was learning disability with offenders in a secure setting. He was criticised for giving expert opinion on matters outside his competence and suspended for three months. However, one can see how an orthopaedic spinal/hip/knee/foot surgeon might be similarly criticised for giving an opinion on a hand injury or similar…beware.

Expert medical reports are commissioned in both personal injury claims and potential medical negligence cases. While it is reasonable for newly appointed consultants to carry out personal injury work I don’t believe that they should consider giving expert opinions in negligence cases until they have considerable experience at consultant level under their belts. There are no hard and fast rules on this but if challenged I would argue that at least 10 years’ experience at consultant level is required before anyone should consider giving an opinion on the quality of care provided by their contemporaries.

Getting Started: Training/Courses

A newly appointed consultant is unlikely to have a great deal of knowledge of the medico-legal arena. Twenty to 30 years ago you simply got on with it. Times have changed. There are training courses on everything from report writing and preparing joint statements to appearing in Court run by a number of organisations including the Expert Witness Institute and Bond Solon. There is a very good e-learning course on “Medico-Legal Report Writing in Civil Claims (Core Skills)” provided by Pro-Sols which is worth considering. There are now medico-legal sections in both JTO and B&J360. The BOA “blue book” on medico-legal practice has just been rewritten and will appear in the JTO later this year.

Getting Started: Networking

If you are going to build up a medico-legal practice you need to let the people who would be responsible for issuing or passing on instructions know who you are and that you are competent and available. Instructions will come from agencies, solicitors or insurers. It may be necessary, in order to get into the market, to work with/through agencies. Usually they pay lower fees, have tight deadlines and may ask you to defer payment for a period of time (6-12 months, occasionally longer). Agencies control a large part of the market and it will be difficult to break in without taking on some agency work. There are a number around but the main players are Capita (was Premier Medical), Premex and Mobile Doctors.

However, the best way to get into the marketplace is to build relationships with solicitors who specialise in this work. Most areas have Medico-Legal societies where doctors and lawyers get together to discuss topics of common interest. These are useful places to make contacts. Review the local press to see which solicitors advertise their services for personal injury claims. Write to them and arrange a meeting with the partner responsible to discuss how you might get involved. Those who request reports are always complaining about delays for appointments and delays for submission of reports. If you are able to guarantee a quality report with a rapid turnaround then you may be able to negotiate a deal or start a working/business relationship.

Getting Started: Mentoring

Whichever department you are appointed to there will invariably be one or more of the senior members who have a significant medico-legal practice. Sit down with them and express your interest in the field and ask for guidance and possibly introductions to local solicitors for “lower end” work. Sit in on a few medico-legal clinics to see how your senior colleague works in this sphere. Work out how he/she organise their practice.

Getting Started: Administrative & Secretarial Support

Clearly, a newly appointed consultant is not going to be able to justify a full time private and medico-legal secretary/PA. However, as soon as is financially practical the operation must be set up and run on a business like footing and not shoe-horned on to the back of an NHS practice. When this is possible will depend on the intensity and success of the marketing process discussed earlier. A good medico-legal secretary/PA is worth his/her weight in gold.

As soon as practical set up a website and have terms and conditions that outline your fees clearly, including Court appearance and

Setting up a Medico-Legal PracticeMichael Foy

call 0800 146 307

email [email protected]

You may have spent years studying and working hard to secure yours and your family’s financial future – but have you considered the impact taking long-term sick leave would have on these finances? If the unexpected happened, it may be too late to consider income protection. Don’t wait for an accident to happen, for peace of mind get a tailored income protection plan from PG Mutual which will pay you a monthly benefit until you’re able to return to your professional career.

*Legal & General, 2014. **Please note this offer is subject to underwriting and PG Mutual’s terms and conditions, applies to new PG Mutual members only and excludes uplifts. It cannot be used in conjunction with any other offer. PG Mutual is the trading name of Pharmaceutical & General Provident Society Ltd. Registered office: 11 Parkway, Porters Wood, St Albans, Hertfordshire AL3 6PA. Incorporated in the United Kingdom under the Friendly Societies Act 1992, Registered Number 462F. Authorised and regulated by the Financial Conduct Authority, Firm Reference Number 110023.

DID YOU KNOW...…the average Briton has enough savings to live off for just 26 days if they unexpectedly lost their income*How long would it be before your money ran out?

FOR BOTA MEMBERSEXCLUSIVE OFFER

Visit www.pgmutual.co.uk/Quotation and enter discount code ‘BOTA’ for your free, no-obligation quotation.

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cancellation fees. When starting up it is difficult if not impossible to impose terms and conditions and you need to tread carefully. However as your practice builds this should be your aim. It is useful to have your CV and T&Cs as a pdf on the website so that instructing parties can download them directly.

Getting Started: Indemnity Insurance

In the old days experts were immune from litigation, i.e. they could not be sued no matter what quality of report/service they provided. That all changed after Jones v Kaney in 2011 where an expert changed their opinion when preparing a joint statement with another expert without any clear reason. This substantially reduced the value of the claimant’s case. The expert was successfully sued and the legal precedent changed. Therefore it is important to ensure that you have appropriate indemnity cover through your defence organisation or insurer.

Conclusions

Hopefully these points will give you some help in breaking in to the medico-legal world when you attempt to set up a practice to complement your NHS and private practice. It needs to be thought through and organised properly. Poorly worded comments and opinions in an expert report can come back to haunt you months or years later. However the principles espoused by Sir William Osler many years ago apply to medico-legal practice in the same way that they do to clinical practice…availability, affability and ability.

Want to move your career to the next level?Your story starts here…If you are looking to gain the skills and qualifications to progress your career in orthopaedics, our practice based postgraduate courses have been designed in collaboration with both nationally and internationally renowned Consultant Surgeons to move your career forward.

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JOINT 61

Want to move your career to the next level?Your story starts here…If you are looking to gain the skills and qualifications to progress your career in orthopaedics, our practice based postgraduate courses have been designed in collaboration with both nationally and internationally renowned Consultant Surgeons to move your career forward.

Professional courses

❚ Trauma and Orthopaedics

❚ Trauma and Orthopaedics: Lower Limb

❚ Trauma and Orthopaedics: Spinal

❚ Trauma and Orthopaedics: Upper Limb

❚ Leadership and Management for Healthcare Practice

With our flexible approach, you can take single modules on

a standalone basis or complete a Postgraduate Certificate or

full Masters.

Interested in conducting your research at Salford?

We enjoy an international reputation for the quality of our

research and invest heavily in multi-disciplinary research,

which improves health and social care provision. Why not

play your part in this story by taking an MPhil or PhD?

For more information please visit:

www.salford.ac.uk/chsc

If you want to talk to someone you can contact our dedicated Course Enquiries Service:

e: [email protected] t: +44 (0) 161 295 4545

BOTAHG Ad_Full page.indd 1 14/08/2014 16:14

Have you ever wondered how one gets to review books for the journals?

The reviewers must be highly regarded experts, who are invited via some sort of secret handshake? Not so…journals are grateful to receive reviews from a wide variety of reviewers, including trainees. If you have just passed the exam, you are probably an expert on ‘how to pass the exam’ type books. (Or very talented. Or extremely lucky.)

You are probably also far more knowledgeable than more senior surgeons about the web and the latest apps.

Publishing book, web, software and app reviews are fun, shows enthusiasm and adds a line to your CV. It doesn’t carry quite the same weight as publishing a Level 1 study in a peer-reviewed journal, but it’s a lot quicker and easier, and you often get a free book!

I am ‘associate editor for web, app and book reviews’ for the Bone & Joint Journal (BJJ). This means that every month I have to twist enough arms to get two reviews ready for print. The journal receives books for review from publishers, and I see apps, programmes or websites that I think are interesting, and I try to find suitable reviewers. I accept pieces from reviewers reviewing a book they already own or a website or app they have used. And in a pinch I review books I have read recently – but I’m a hip specialist – so I don’t have a very wide repertoire.

The BJJ is read around the world, and therefore I try to select books relevant worldwide and I am happy to publish reviews of books in any language. Recently we have reviewed lots of books on orthopaedics, as you would expect, but also on healthcare economics and medical history, various apps including a logbook, and image management software.

Reviewing is not a black art (almost anything goes), but good reviews should inform the potential reader. If you fancy trying your hand, here are a few pointers:

• Read a few reviews at http://www.boneandjoint.org.uk/content/book-reviews

• Have a look at the publisher’s own book description – most easily found at Amazon or at the publisher’s website. What do they think is special about the book? They usually give useful information like ‘the book is completely reorganised into such and such a format for the nth edition, with n new chapters and n specially-commissioned line drawings of all the whatever…’

• Does the publisher’s review and the blurb on the back cover actually match the content? They occasionally mislead with something like ‘in depth coverage’ of a subject which actually only gets a few paragraphs.

• Who are the authors and editors? What is the geographical flavour? Are they all from the UK, North America or Europe, or are there authors and experience from other places – particularly the third world?

• Write a general overview of the book.

• If you wish, make specific comments on aspects of the content, especially if the content is not clear from the publisher’s information.

• If there are previous editions, compare the present edition to the last edition–in other words is it worth getting the new edition if you already have the previous edition?

• Comment on the overall tone of the book–aggressively latest techniques, or more circumspect?

• How relevant is the content outside of modern well-equipped hospitals?

• Is it mainly relevant to the general orthopaedic surgeon, or only to subspecialists?

• Is it mainly relevant to trainees or consultants, or both?

• Any other comments as you wish.

There is even less of an agreed format for web and app reviews, but common sense often prevails. A brief overview followed by screenshots with captions usually works pretty well. The BJJ publishes a 200 word summary in the printed edition and puts the full review on the web.

Got an idea for a review, or just want to join the BJJ reviewer’s panel? Email me! [email protected]

Ever Thought of Reviewing Books for the Journals…?Jason Brockwell

Web and Book Reviews

We welcome reviews or suggestions for reviews and reviewers of books, websites and apps. Reviews are accepted in English, Spanish and Chinese. The book, website or app may be in any language. Please email suggestions for reviews and reviewers to [email protected]

Jason BrockwellAssociate Editor for Web and Book Reviews

APPShoulderTherapistReviewed by Mr Tom LewisReview excerpt:Shoulder surgeon Lennard Funk, orthopaedic trainee and app developer Ronnie Davies, and three specialist shoulder physiotherapists have developed a unique pair of mobile apps to help physiotherapists rehabilitate shoulders. There are two apps — one for the patient and one for the therapist. Therapists install the ShoulderTherapist app and patients install the ShoulderPatient app. The therapist uses

the app to create a rehabilitation exercise programme, which is transferred to the patient’s iPhone via Bluetooth. Using paired apps to organise a rehabilitation programme is a novel concept.

There are no pre-installed rehabilitation programmes to prevent patients from using the ShoulderTherapist app to attempt their own rehabilitation without supervision – the therapist must create each programme by choosing exercises, hold times and repetitions. This technology should help to improve patient understanding and compliance and save therapists time. Shoulder surgeons should try out these apps. Surgeons and therapists dealing with other anatomical areas may be intrigued and inspired by their potential.

iTunes: Search for ShoulderTherapist/ShoulderPatient

BOOKOrthopaedic basic science for the postgraduate examination: Practice MCQs and EMQsS. J. Dawson-Bowling, I. R. McNamara, B. J. Ollivere. Orthopaedic Research UK (www.oruk.org), 2012. £39.95Reviewed by Mr Luke Brunton, Orthopaedic Trainee

Review excerpt:This book is a comprehensive cover of basic science to help those undertaking the part 1 written FRCS (Tr & Orth) or equivalent exams. It is published by Orthopaedic Research UK and written by three orthopaedic surgeons with up-to-date experience of the exam. (One of them is on the Editorial Board of this journal and edits a related journal.)

Fifteen key topics in basic science are nicely split into specific chapters making review of the topics easy. At the end of each chapter a clear and concise explanation to the answers is given, and a comprehensive index at the end of the book aids rapid access to key topics.

Practice multiple choice questions are widely available, but it is much harder to find extended matching questions (EMQs). This book contains over 500 questions, of which 150 are EMQs.

The difficulty of the questions is appropriate and varied and the time it takes to go through the questions closely matches that of the real exam. I gauge the overall difficulty as a little harder than the actual FRCS examination.

The book is written for British examinations, but is appropriate for international trainees undertaking board or equivalent examinations.

It fills a gap in preparation for the FRCS written examination.

Read the full review at www.boneandjoint.org.uk/content/book-reviews

Read the full review at www.boneandjoint.org.uk/content/web-app-reviews

Pros: • Bluetooth distribution of patient-specific physiotherapy regimes

• Wide range of exercises • Exercises explained using pictures and text• Referenced• Paperless• No pre-installed rehabilitation programmes

Cons: • No pre-installed rehabilitation programmes

• Paperless• iPhone only

JOINT62

Prizes and Bursaries

ORUK Prizes 64

Podium Presentations 64-65

ORUK Winner Poster Prize 66-67

ORUK Runners-up Poster Prize 66

Junior Essay Prize sponsored by Acumed 68

Junior Members Winning Essay 2014 68-69

Cambridge Orthopaedic Writing Prize 70

Winning Essay 2013 – Doctors are a Drain on Society 71

BOTA Medical Student Elective Bursary Winner – Zambia 73

BOTA Medical Student Elective Bursary Winner – Australia and Vanuatu 74-75

JOINT64

Overall Winner: Benjamin Dean

The Neurohistology of Painful and Pain-free Tendons

Dean B1, Franklin SL1, Murphy RJ1, Benson R1, Javaid M1, Carr AJ1

1. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford

Introduction

Rotator cuff tendinopathy (RCT) is the most common cause of shoulder pain. There is a strong association between tendon structure and pain symptoms.

Objective

Our main objective was to compare the tendon neurohistology between one group of patients with pain and one group of patients without pain.

Methods

Supraspinatus tendon specimens were obtained by ultrasound guided biopsy from 9 patients with painful RCT resistant to conservative management (painful group) and 9 pain-free patients at over 6 years following subacromial decompression (SAD) (pain-free group). Pain symptoms were measured using the validated Oxford Shoulder Score (OSS). Structural tendon integrity was assessed ultrasonographically. Basic histological staining and immunohistochemistry was performed. Mann-Whitney U tests were used to test for differences between groups.

Results

The groups were similar in terms of age, sex and structural tendon abnormality. The leucocyte count (CD45 positive cells) and macrophage count (CD68 positive cells) were increased in the painful group versus the pain-free group (p=0.01 and 0.05 respectively). The expression of the metabotropic glutamate receptor 7 (mGluR7) was reduced in the painful group versus pain-free (0.002). PGP 9.5 (a nerve marker) expression was increased in the painful group versus pain-free (p=0.008).

Conclusion

Specific neurohistological tendon changes are associated with the resolution of pain post SAD. These findings are novel and improve our understanding of pain in RCT. The glutaminergic system may provide novel therapeutic targets in managing pain in RCT.

Podium Presentations

The BOTA educational weekend once again provided an opportunity for trainees to showcase their research as part of the BOTA ORUK research prize. We had well over 100 high quality entries and as such we ran the poster prize over two days and also introduced a new podium presentation section.

This year’s podium presentation was won by Ben Dean from the Botnar Institute in Oxford for his work on ‘the neurohistology of painful and pain-free tendons’. Runners-up were Adam Smith and Mustafa Rashid.

We would like to thank ORUK for their continued support with prizes and certificates.

ORUK PrizesRamsey Refaie

JOINT 65

Runner-up: Mustafa Rashid

A Biomechanical Evaluation of Vancouver Type B1 Femoral Periprosthetic Fracture Fixation Using a Purpose-Designed Plating System

Rashid M1,2, Gee M1, Achan P1, McRory J1, Pullin R2

1. The Royal London Hospital, Whitechapel, London

2. Cardiff School of Engineering, Cardiff University

Introduction

Femoral periprosthetic fractures around a well-fixed femoral implant are challenging to treat successfully. Different methods of fixation for these fractures have demonstrated mixed success rates. Research using these newer systems is required to inform Orthopaedic surgeons which configuration of fixation provides sufficient stability to prevent fixation failure.

Objective

To evaluate the stiffness, strain, and mechanical behaviour of four different configurations of femoral periprosthetic fracture fixation around a well fixed prosthesis.

Methods

Four different configurations using the NCB system to fix femoral periprosthetic fractures around a stable cemented collarless, polished, tapered femoral stem (CPT, Zimmer) were prepared using composite synthetic femora. Constructs tested had increasing degrees of cement mantle intrusion from none (cables-only) to six bi-cortical locking screws in the proximal fragment. Constructs were loaded in three modes, then cyclically loaded in axial compression, and post-cycling loading to determine the overall stiffness and maximum load to failure.

Results

Pre-cycling mechanical testing produced erratic results, however, after cycling, ‘bedding in’ of the prosthesis into the cement mantle occurred and there was a reliable correlation observed. Bi-cortical locking screws in the proximal fragment inferred the greatest construct stiffness, particularly in torsion. A trend was observed with progressive decrease in cement mantle intrusion. The cables-only construct was deemed to be the least stiff and unsatisfactory for fixation stability.

Conclusion

Polyaxial bi-cortical locking screws that breach the cement mantle and bypass the femoral stem leads to greatest construct stiffness. Cables-only fixation does not provide sufficient stability to prevent excessive displacement and should be avoided.

Runner-up: Adam Smith

Pre-operative Nutritional Serum Parameters are Associated with Failure of Internal Fixation in Undisplaced Intracapsular Hip Fractures in the Elderly

Smith A1, Bajada S1, Morgan D1

1. Trauma & Orthopaedic Department, Royal Glamorgan Hospital

Introduction

The aim of this novel study was to examine if nutritional status was associated with failure of internal fixation. Hip fractures account for many acute hospital admissions in patients >60 years. These patients are often malnourished. Current management of undisplaced intracapsular hip fractures is based on internal fixation. Reported revision rates of 12-17% impact on patient morbidity and mortality, and increase costs.

Methods

A consecutive series of 94 elderly patients (>60 years old) admitted over a three year period with undisplaced intracapsular hip fractures treated with cannulated screw internal fixation were retrospectively reviewed. Nutritional status was assessed using total serum protein, albumin, and total lymphocyte count (TLC) levels. Ondera’s Prognostic nutritional index (OPNI) scores were calculated. Radiographs were used to assess fracture classification, posterior tilt, fixation adequacy, screw configuration and failure. Failure was defined as avascular necrosis, non-union or screw cut out at a minimum of three months post surgery.

Results

Seventy-seven patients were available for analysis. 13% of fixations failed during the study period. Patients with fixation failure had a significantly lower TLC (800 vs 1400, p=<0.001) than non-failure patients. TLC (p=0.008 (CI 1-1.01) and OPNI (p=0.014 (1.06-1.67) were independently predicative of failure of fixation. Results were compared with an independent age matched control group.

Conclusion

This is the first study to report that nutritional parameters are associated with failure of fixation of undisplaced intracapsular fractures. Specific nutritional support could be provided and consideration of arthroplasty instead of screw fixation for those at highest risk of failure.

JOINT66

ORUK Runners-up Poster Prize

ORUK Winner Poster PrizeThree prizes were also awarded for this year’s poster competition. We congratulate the winner Oliver Boughton for his work ‘Odontoid process fractures: The role of the ligaments in maintaining stability: A biomechanical cadaveric study.’ Runners-up were Amresh Singh and Ashley Scrimshire.

Winner: Oliver Boughton

Odontoid Process Fractures: The role of the Ligaments in Maintaining Stability: A Biomechanical, Cadaveric study

Runner-up: Amresh Singh

The Virtual Fracture Clinic Pathway – A Novel Approach in Trauma Patient Management in England

Singh AP1, Nicholai PA, Porteus MJL, Deakin S

1. West Suffolk Hospital, Bury St Edmunds

Introduction

In the Virtual Fracture Clinic (VFC), an orthopaedic consultant assesses the history, examination and radiographs from A&E. Based on this a plan is made, either to discharge or bring to a timely or specialty specific fracture clinic. Each patient receives a phone call to discuss the plan. There is a telephone line for any patient concerns.

Objectives

To share our early experience of the VFC in a DGH, assess effect on clinic numbers and patient satisfaction.

Methods

Patient satisfaction survey done before and after introduction of VFC. Clinic numbers assessed over a six week period after start of VFC and compared to the same period a year ago.

Results

High patient satisfaction pre and post VFC was maintained. Of the patients brought back to clinic, 97% felt the phone call was helpful and 95% knew how to ask for help. All patients felt that they had enough information. Of the people discharged directly, 91% would recommend the service and 97% found the phone call helpful. Average number of patients in each VFC was 27 with 42.7% discharge rate. There was a 33% reduction in new patients per clinic and 25% reduction in overall clinic size. Average waiting time decreased to 13 minutes.

Conclusion

The VFC is a new approach to the outpatient management of trauma patients in England. It provides a more directed approach with advice and discharge or specialised opinions. Communication by telephone was well received and patient satisfaction maintained. It prevents unnecessary attendances, saving time and minimising patient inconvenience.

Runner-up: Ashley Scrimshire

A Novel Technique for In Situ Pinning of Slipped Capital Femoral Epiphysis to Prevent Growth Arrest

Scrimshire A1, Gorva A1

1. Alder Hey Children’s Hospital, Liverpool, England

Introduction

Slipped capital femoral epiphysis (SCFE) is typically treated with single screw fixation. One problem with this is the screw threads cross the physis causing growth arrest. This means either; screws require removal or leg length discrepancies occur.

Salihan used specialist proximally threaded screws with no thread crossing the physis, preventing growth arrest. This technique required a high proportion of re-operation(30%) due to the screw backing out.

We present a novel method to overcome these problems.

Methods

A 9-year old male with spontaneous, stable left SCFE underwent bilateral screw fixation. Using the general rule that male proximal femoral growth rate is 3mm/year, the patient’s remaining growth potential was 1.8-2.1cm. Using pre-operative x-rays epiphyseal depth and required screw length were measured, allowing 2cm protruding from the lateral femoral cortex.

Using a diamond cutter a standard 7.3mm cannulated screw with 16mm thread was shortened leaving 9mm thread. Using a standard lateral percutaneous approach a single screw was inserted bilaterally ensuring the threads did not cross the physis.

Results

Post-operatively the child made a good recovery and was discharged home the following day. He was partially weight bearing for six weeks and is now mobilising freely. He is nine months post-operation, has suffered no complications and x-rays confirm the screw remains in situ.

Conclusion

By securing the screw within the femoral epiphysis and leaving the smooth screw shaft for femoral neck growth our method allows for continued growth following SCFE pinning and potentially prevents screws backing out, without the need for specialist equipment.

Aims!The current investigation studied the role of the cervical ligaments in maintaining atlanto-axial stability after fracture of the odontoid process

Odontoid Process Fractures: The role of the Ligaments in Maintaining Stability: A Biomechanical, Cadaveric Study!

Oliver Boughton1,2, Matthew Szarko1, Mark Harris2, Timothy Bishop2, Jason Bernard2!

1St George’s, University of London; 2St George’s Healthcare NHS Trust, London!

Methods 13 fresh-frozen cadaveric cervical spines were dissected to prepare a C1-C2 vertebral block for biomechanical analysis. The C1 and C2 blocks were mounted and mechanical analysis was performed. Mechanical properties including Young’s modulus (stiffness), was assessed for right rotation, left rotation and anterior displacement. Right and left rotations involved 9mm of movement, whilst anterior displacement was limited to 3 mm of movement. These values were identified to be non-destructive which allowed the testing of the sample more than once. The C1-C2 complex was tested in a natural condition, after creating an Anderson and D’Alonzo type II fracture, and successive division of the atlanto-axial ligaments.

Results First dissection group (first 8 specimens): Young’s modulus calculated after mechanical testing of 1.  Undissected specimen 2.  Specimen after fracture of the odontoid process 3.  Successive division of facet joint capsules 4.  Division of ligamentum flavum 5.  Division of Anterior Longitudinal Ligament (ALL)

Figure 6: Dissection Group 1. Graph showing successive reduction in the stiffness of the C1-C2 complex after successive division of the structures. Stiffness of dissected specimen represented as a percentage of the stiffness of the undissected C1-C2 complex. On x axis 1: Undissected specimen; 2: Specimen after fracture of the odontoid process; 3: Successive division of facet joint capsules; 4: Division of ligamentum flavum; 5: Division of Anterior Longitudinal Ligament (ALL)!!

Figure 1: Anderson and D’Alonzo classification of fractures of the odontoid process of the axis (C2 vertebra). Illustrations courtesy of Mr Stefan Lazic!

Figure 3: Photograph of a fresh-frozen cadaveric C1-C2 complex undergoing anterior-posterior stiffness testing!

Figure 5: Graph showing Stress vs Strain in the undissected specimen in antero-posterior displacement biomechanical testing. Plotted red line represents Young’s modulus which is 0.977 MPa in this undissected specimen!

Second dissection group (second 5 specimens): Young’s modulus calculated after mechanical testing of 1.  Undissected specimen 2.  Specimen after fracture of the odontoid process 3.  Successive division of Anterior Longitudinal Ligament (ALL) 4.  Successive division of Posterior Longitudinal Ligament (PLL)

Conclusion •  The odontoid process accounts for up

to 50% of the stiffness of the C1-C2 complex

•  Soft tissue structures account for further resistance to movement

•  We suggest MRI imaging of the soft tissues in an acute odontoid process fracture to help determine the stability of the fracture and manage the injury

[email protected]!

Figure 4: Photograph of a fresh-frozen cadaveric C1-C2 complex undergoing lateral rotation stiffness testing!

Figure 7: Dissection Group 2. Graph showing successive reduction in the stiffness of the C1-C2 complex after successive division of the structures. Stiffness of dissected specimen represented as a percentage of the stiffness of the undissected C1-C2 complex. On x axis 1: Undissected specimen; 2: Specimen after fracture of the odontoid process; 3: Successive division of Anterior Longitudinal Ligament (ALL); 4: Successive division of Posterior Longitudinal Ligament (PLL)!!!

Type 1!

Type 2!

Type 3!

5!

6!

!4!

1!

2!

3!

Figure 2: Illustration of a sagittal section of the C1-C3 cervical vertebrae. 1: Anterior arch of atlas (C1); 2: Odontoid process of the axis (C2); 3: Anterior longitudinal ligament; 4: Transverse ligament of the atlas; 5: Ligamentum flavum; 6. Posterior longitudinal ligament. Illustration courtesy of Mr Stefan Lazic!

JOINT68

Introduction

Intramedullary (IM) nailing has long been the gold standard treatment for closed diaphyseal fractures. Recent years have seen advances in indications for its use, including treatment of selected metaphyseal fractures and open fractures.1

IM nailing has been documented as far back as the 16th century, when Mexican anthropologist Bernardino de Sahagun2 reported the use of IM wooden sticks for the treatment of longbone non-union in the Aztec population.3 The 1800s saw numerous IM nailing techniques and materials being tried, including ivory pegs4 distal locked ivory nails,5 autogenous bone pegs6 and solid metallic nails.7 All had poor success rates with complications including high infection rates, metallosis and fatigue failure.1,3

The first successful IM nailing was reported in 1931 when Smith-Peterson successfully used a stainless steel IM device for a femoral neck fracture. During the next decade the Rush family and Gerhard Kuntscher developed many of the concepts of modern day IM nailing. Over the last 70 years implant design has advanced due to industry development, changes in surgical techniques and implant materials. However, it is truly remarkable to consider how little of Kuntscher’s original principles and technique have changed.

Kuntscher’s Revolution

Gerhard Kuntscher is largely credited as the forefather of modern reamed IM nailing and undoubtedly revolutionised the management of long bone fractures. Born in 1900 in Zwickau, Germany, Kuntscher worked as a Military surgeon. His original IM nail design (1939) was an antegrade, V-shaped, stainless steel, slotted “marrow nail.” This was the first successful IM fixation for diaphyseal fractures.3 He applied the biomechanical principles of the successful Smith-Peterson nail for femoral neck fractures to diaphyseal fractures, allowing internal splinting, elastic union and early functional mobilisation.1,3

In Germany, the concept of IM nailing was initially met with scepticism and disapproval. However, whilst serving in Finland during the Second World War Kuntscher continued to practice and teach his technique. Later, in 1947, Kuntscher and Finnish colleagues published a report of 105 patients treated with the V Nail.3 IM nailing was largely unknown around the world prior to WW2 until prisoners of war returned home with evidence of Kuntscher’s legacy embedded in their medullary canals. This led to various worldwide publications including the 1945 US case report “Amazing Thighbone.”8

Over the course of his career Kuntscher collaborated with instrument maker and metallurgist Pohl, and in the late 1940s changed from the V shaped nail to the corrosion resistant, stainless steel, slotted, cloverleaf design that earned him worldwide accolade.9 Kuntscher is responsible for championing many of concepts upon which modern nailing is founded including consideration of fracture biology, nail design, closed reduction techniques, fluoroscopy, flexible reaming and locking screws.

Early in his career he recognised the importance of protecting the soft tissues and respecting the fracture biology. His original technique recommended insertion of the nail distant to the fracture site to prevent further damage in the zone of injury.9 He also pioneered techniques including closed reduction using multiple intraoperative slings and head worn fluoroscopy for intraoperative imaging. Closed reduction was briefly abandoned in favour of open reduction in the 1950s amidst concerns of radiation side effects associated with head worn devices. Development of image intensifiers in the 1960s allowed re-popularisation of Kuntschers original closed technique.3

Junior Members Winning Essay 2014 A History of Intramedullary Nailing – Sara Dorman

Junior Essay Prize sponsored byJames Shelton

I would like to introduce the winner of the annual British Orthopaedic Trainee’s Association Acumed Junior Essay Prize. The continuity of this competition, allowing our junior membership to exhibit their literary talent was only made possible by the generosity of Acumed who donated the truly outstanding prize of an iPad mini. The winner of the junior essay prize with the essay ’The history of the intramedullary nail–Kuntsher to present day’ was Ms Sara Dorman (CST2 Mersey). She was thrilled to receive this prestigious award at the BOTA Educational Weekend and AGM at Carden Park this year. She has subsequently been elected to the position of Publicity Representative on the BOTA committee and we wish her the best of luck with the publication of JOINT next year!

The title of the BOTA Junior Essay Prize 2015 is…

‘Is 3D Printing, the future to picture perfect orthopaedic surgery?’ (800 word limit)

Deadline: December 10th 2014 (result announced January 10th 2015)

JOINT 69

The Reamed Nail

Fischer (1942) first reported the benefits of IM reaming and large diameter nails in increasing fracture stability, through increased contact area. Kuntscher supported this belief and reported that IM reaming of the endosteal surface was essential in permitting the insertion of the largest possible diameter nail to prevent fatigue failure, ensuring an accurate fit with increased endosteal bone-nail contact. He developed a number of reamers throughout his career culminating in development of a flexible guided reamer to allow closed, reamed IM nailing.9

Interlocking Nails

Modny and Bambara in 1953 introduced the concept of interlocking screws.10 They reported success with a cruciate shaped nail with multiple interlocking screws at 90 degrees orientation.3 A later case series of 261 patients demonstrated excellent success rates.11 In 1968 Kuntscher introduced the “detensor” nail for comminuted fractures, a precursor to the interlocking nail. He recommended the use of a single pin above and below the fracture site to prevent shortening, angulation and mal-rotation. In 1972 Kuntscher and Klemm renamed it the “interlocking nail”.1

Unreamed Nails

Around the same time as Kuntscher, the Rush family pioneered the development of the unreamed nail. Initially they reported the use of metallic Steinman pins and cerclage wires for intramedullary fixation of Monteggia fractures.12 Later they developed an unreamed, smooth, stainless steel intramedullary nail with a proximal bend named the “Rush Pin”. They introduced the ender pin as a more flexible alternative to the rush pin. However due to the unreamed, narrow diameter, non-locking design of these nails, high rates of longitudinal and rotational instability often resulted in the need for additional stabilisation techniques.13 For these reasons in current practice unreamed, unlocked nails are not commonly used. The main indications for newer titanium elastic nails are upper limb diaphyseal fracture stabilisation in any patient groups and lower limb fractures in paediatrics.

Similarly unreamed, locked nails have largely been superseded by advances in the reamed, locked nail. However they may still be indicated in certain patient groups when there are specific concerns regarding reaming of the medullary canal. The Russell and Taylor femoral nail was originally designed for use in this group as a large diameter, slotted alternative to the reamed, locked nail.9 Newer designs of unreamed, locked nails have also gained in popularity and expanded the indications for use. Examples include fibula IM nailing, which is particularly useful in patients with compromised soft tissues.

Current Advances

Since Kuntscher and Rush, IM nails have undergone a number of design modifications. Anatomical nails have gained in popularity as they account for the natural shape of the medullary canal, reducing the risk of cortex perforation and allowing for insertion of maximum diameter nails.9 Slotted designs have also been largely replaced by non-slotted designs to improve torsional rigidity.3

Advancement in technology has allowed for the development of proximal locking jigs to facilitate accurate insertion of proximal locking screws. Distal locking however is often a source of surgical time delays. Recent developments include specialised targeting systems and virtual real-time imaging systems such as ‘SURE SHOT’ to facilitate distal locking and reduce radiation exposure.

Conclusion

Intramedullary nailing technology has advanced significantly over the last 70 years to become the gold standard treatment for long bone fractures requiring surgical intervention. The principles of IM fixation however have remained largely unchanged since the original technique pioneered by Kuntscher.

References

1. Vecsei V, Hajdu S, Negrin L. Intrameduallry nailing in fracture treatment: History, science, and Kuntschers revolutionary influence in Vienna, Austria. Injury. 2011. 42(s4):s1-s5.

2. Farill J. Orthopedics in Mexico. The Journal of Bone and Joint Surgery. 1952. 24(Am):506-12.

3. Bong M, Egol K. The History of Intramedullary Nailing. Bulletin of the NYU Hospital for Joint Diseases. 2006. 64(3-4):94-97.

4. Bircher Eine neue Methode unmittelbarer Retention bei Fracturen der Rohrenknochen. Arch Klin Chir. 1886. 34:410-22.

5. Gluck T. Autoplastic transplantation. Implantation von Fremdkörpern. Berl Klin Wochenschr. 1890. 19.

6. Hoglund EJ. New method of applying autogenous intramedullary bone transplants and of making autogenous bone-screws. Surgery, Gynecology & Obstetrics. 1917. 24:243-246.

7. Hey Groves EW. On the application of the principle of extension to comminuted fractures of the long bone, with special reference to gunshot injuries. British Journal of Surgery. 1914. 2(7):429-443.

8. Time Magazine. Amazing thighbone. 1945. Available at: http://content.time.com/time/magazine/article/0,9171,797257,00.html

9. Courtbrown CM. An atlas of closed nailing of the tibia and femur. 1991. London: Martin Dunitz Publishing.

10. Modny MT, Bambara J. The perforated cruciate intramedullary nail: Preliminary report of its use in geriatric patients. Journal of the American Geriatrics Society. 1953. 1:579-588.

11. Modny MT, Lewert AH. Transfixion intramedullary nail. Orthopaedic Review. 1986. 15:83-88.

12. Rush LV, Rush HL. A technique for longitudinal pin fixation of certain fractures of the ulna and of the femur. The Journal of Bone and Joint Surgery. 1939. 21(Am):619-626.

13. Ruedi T, Buckley R, Moran C. AO basic principles in fracture management. 2007. Switzerland: AO Foundation Publishing

JOINT70

It is a natural assumption that authors who have published numerous scientific papers have also acquired mastery of the written word. Sadly this is not always the case. Talk to many journal editors and they will say that a number of the submissions they receive fail because an interesting finding has simply been presented in a poor way. However good the idea, however well conducted the

research, the paper has fallen at the final hurdle for no reason other than being written badly. No reader should have to struggle to understand an author’s words.

At this point enter the Cambridge Orthopaedic Writing Prize, created to allow freedom of written expression and to encourage trainees, authors, writers – call them what you will – to have fun, to play with their language and, at the same time, to compete. The end game, of course, is for the quality of scientific submissions to improve; for entrants to realise that you can influence a reviewer’s judgment simply by improving the language and presentation of submitted research. There are no prizes for hopeless complexity. How can one expect a reviewer to focus on a paper that is badly written? Not a hope. Reviewers are human too.

For this year’s prize, the judges were bowled over with the professionalism and content of the submissions. Each one, in their view, was utterly brilliant. Blood was almost spilt when it came to making the decision as to who might win. Indeed, from the six judges, there were almost as many views as there were prize entries. So if you have entered but on this occasion failed to either win or become a runner-up, please be absolutely assured that your entry was well read, much appreciated and hugely enjoyed.

Oh yes, I almost forgot. Next year? Of course there is a next year. I very much hope past entrants will enter again and those who did not enter will decide to have a go. After all, what is there to lose? There could be everything to gain. The title has once more been the result of much discussion and here it is.

Cambridge Orthopaedic Writing PrizeRichard Villar

The title for the Cambridge Orthopaedic Writing Prize 2014 is…

“Healthy living sucks” So go on then, give it a go. Precisely 1000 words, any genre

Deadline: December 31st 2014

Full entry details are on our web site (www.cambridgeorthoprize.com)

JOINT 71

Doctors are a drain on society. Perhaps we are. The social hub of society is ‘The Dinner Party’ and I am certainly a drain at dinner parties. The smart, yet casual, social haunt of anyone with a degree and a job that earns them over 20k. Whilst everyone discusses the latest office gossip and chortles about business meetings that ‘ended with Jerry stood on the table serenading the Princess of Sweden!’ I am there, pale from living a nearly nocturnal life on nights and probably riddled with scurvy having given up all food except for toast from the mess.

‘So how is your job as a DOCTOR?’ ‘Oh perfect I’ve been on-call so managed to hold a wee in for 12 hours and walked around for 4 hours today with an old ladies blood on my face thanks to an overzealous ortho registrar with a saw and an intracapsular NOF! You would think someone would have told me…’ I had them at ‘blood’ and lost them at ‘ortho registrar’. Smug James who works in ‘The City’ has suddenly lost his appetite for the rare steak we are all enjoying and my non-medic friends once again push food round their plates and wonder when I’m next on-call.

We certainly are a drain on ink at the tabloid printers. Tabloid newspapers appear to be the fodder of society. What society grazes on whilst utilising the public transport system. When they have finally run out of stories about Princess Diana and have completed 50 shades of xenophobia we often are allowed our 15 minutes of fame. ‘Doctors More Hated Than Bankers’…apparently. I’m certain I would take this national disgust much better from the padded leather seats of my private jet after back to back meetings in Deutsche Bank’s pools of gold.

Everyone in society also loves a good ‘Doctor Missed My Unpronounceable Eponymous Syndrome’ tale; what failures we are. Between magazines showing hideous scars from botched boob jobs in Bradford to demonic doctors poisoning their lovers we make flashy and disgraceful headlines. Our mumbling faux empathy and fatigued demeanour is no match for the newspapers Tuesday Medical Section or indeed Dr Google. Dr Google (although often telling porky pies) gives free, instant, unapologetic answers and never botches a boob job. He certainly is not a drain on society; unlike us.

When society isn’t feeding off news and discussing it over dinner tables they are happily procreating in wholesome homes. Whether in straight marriages or gay partnerships our society is seemingly built upon the notion that we need to be happily cohabiting with a binding legal contract for life; and with child (or many) to be complete. I’m not. In fact doctors are terrors for the dreaded ‘D word’…divorce. I can close my eyes in a busy hospital canteen and decipher immediately which tables are hosting doctors, indeed which species of doctor. ‘We can’t find a weekend in our rotas for the next 8 months where we are both free to get married!’ certainly the medical registrar, ‘my ex-wife is taking our children to Lake Como this summer’ Surgical Consultant, ‘my second ex-wife is taking our children to Lake Como this summer’ Orthopaedic Consultant.

Our hours, exams and terrible dinner party chat make us our own home wreckers. We are contributing to broken Britain through divorce and absent parenting. Our children will act up in class because they are lacking role models, we are never home and when we are we are tired. ‘Hello, this is the scrub sister can I take a message the doctor is scrubbed? Yes. I will tell her. Sorry to interrupt, your son Damian has bitten another child in Primary 4 and then proceeded to eat all the purple crayons in a fit of rage. The school would like you to come in please and take him home.’ ‘Oh bugger, can I get a 4-0 vicryl please and can you call them back please and ask them to call the nanny.’

I have neglected to mention how we drain the foundation of society, the glue holding us all together in the colony and no, it’s not love or a beautiful desire to work symbiotically with one another (you only need to get on the Tube in rush hour to thank God it doesn’t rely on this). It is money. That piece of paper with the queen’s face stamped on is what holds the whole show together. We drain that. Large amounts of societies cement; precious money that could be spent on new roads and more Boris Bikes. I won’t bore with figures and graphs but it costs a small fortune to turn spotty school nerds into brave life savers (or rheumatologists). Once we are trained we need to work somewhere and society pays out even more money for that as well. The NHS is a black hole guzzling society’s cash; it is the Enron of government institutions. It is a sinking ship but we refuse to jump off, we are still playing Rachmaninov in the water logged dining room and rearranging deck chairs. We keep the vortex open and allow the money to fall in.

We really do drain society from a variety of angles. Sometimes, however, I feel that we may redeem ourselves slightly when the tables are turned and society is trying to drain itself. We are there when society is metaphorically circling the drain. Sometimes we act as plugs for society, not just drains. Plugging arteries when society decides to slam their car into a wall at 75 mph. Plugging tears when we give back hope by offering to remove tumours. Plugging fractured hips with cement and prosthesis just so society can walk again. Plugging holes in hearts so younger members of society can grow up, live and dream. Perhaps we are drains on society in general, but for a few hours a day we get to be plugs and for me that’s enough to justify my draining life as a doctor to society.

Winning Essay 2013 – Doctors are a Drain on SocietyCharlotte Somerville

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JOINT 73

Due to my interest in orthopaedics, and also in working in a low resource setting in the future, I chose Lusaka, Zambia, as my elective destination of choice. Here I was based at the University Teaching Hospital (UTH). This I felt, would allow me to gain experience and apply what I have learnt over the past 4 years in a different, more challenging environment.

The UTH is the main hospital within Zambia serving the densely populated capital of Lusaka. It also serves as the main tertiary referral centre in Zambia, where specialist care may be provided to the country’s population of 14 million. The healthcare system is a mixture of private and public, with patients having to pay for outpatient services such as physiotherapy and surgical implants such as joint replacements, plates and screws. Despite the government funding, I observed many patients who were treated conservatively using skeletal traction methods, purely due to their inability to afford surgical treatment.

For the duration of my attachment, I shadowed one of the five orthopaedic teams in clinics, theatres and on ward rounds. The pathology observed was not too distant from that seen in the UK, however I did see several cases of Pott’s disease in clinic due to untreated TB, requiring long courses of chemotherapy.

As part of my timetable I also attended the clubfoot clinic. Here surgical correction was reserved for the most severe of cases, with the majority being successfully treated non operatively with the Ponseti method.

My first experience of the wards came whilst on a busy consultant ward round. Wards were at full capacity and alongside the hospital beds many mattresses lay strewn on the floor to provide additional beds. It was apparent that many patients presented late to the hospital due to poor accessibility and a cultural tendency towards pursuing alternative medicine before coming to the hospital. This was apparent with several cases of osteosarcoma and similarly chronic osteomyelitis which were diffuse on presentation to the orthopaedic team. In particular I saw an 11 year old boy whose tibial shaft was all but destroyed due to chronic osteomyelitis. As a result a decision was made for his fibula to be grafted to the remaining tibia to provide structural support.

During my time at UTH I also had the opportunity to work with a charity organisation called Flyspec (named from the abbreviated “Flying Specialists”). Operating out of UTH this organisation was founded in 1982 by Professor Jellis (a now retired orthopaedic surgeon at UTH). Equipped with a Cessna light aircraft Professor Jellis began flying to remote areas in order to provide surgical care. And since its inception several other surgeons at the hospital have also joined. I was fortunate enough to join Dr Jovic, Zambia’s only plastic surgeon (and the main pilot!) on a Flyspec trip where we visited Mukinge hospital, a remote mission hospital in the north-west province of Zambia.

Over the course of three days I assisted in a wide range of cases ranging from cleft lip repairs, skin grafts, contractures and keloids. It was clear to see the impact that the more limited funding had, particularly in the mission hospitals. Overall my elective was an incredibly valuable and enjoyable experience. During my time at Mukinge I was able to observe the extremes of surgery in an underprivileged environment, allowing me to see how adaptations may be made to maximise the use of available resources and how surgery may be performed efficiently under such circumstances. Although I expected my experience to be challenging, being in the hospital environment and seeing this range of conditions was still a shock, and presented part of the challenge of working in a low resource environment. This experience has given me the opportunity to develop my surgical, consultation and practical skills all of which will be of benefit in my future career.

BOTA Medical Student Elective Bursary Winner Zambia Michael Ng

JOINT74

The aims of my elective were to witness orthopaedic, trauma and plastic surgery in both world-leading and resource-poor environments. I started at the Department of Orthopaedic Surgery in The Alfred Hospital, Melbourne, a tertiary referral centre whose Emergency Department is the busiest trauma centre in all of Australasia. Almost 2,400 trauma patients are admitted annually, with the majority requiring input from a multitude of surgical teams.

Each day I could choose between attending X-ray meetings, ward rounds, clinics and theatre. The main theatre block had 16 operating rooms, which meant I could pick and choose between orthopaedics, trauma and plastic surgery in order to see a variety of different cases. As a result of this, I was constantly busy and able to participate in multiple cases each day.

In general, the surgical lists were run by senior registrars, all of whom were enthusiastic and grateful to have a student in theatre. I scrubbed in for every single operation, though for the first few days I was only asked to do the standard ‘medical student’ jobs, such as repeatedly holding a leg in the air so the image intensifier could capture images of the opposite limb. After showing commitment in theatre, I was allowed to do more and more until eventually I was using the electric saws, drills, inserting K-wires and closing wounds, albeit under strict supervision. From a surgical perspective, I learnt an inordinate amount of information during my time in theatre, where the registrars made time to teach.

I was able to participate in a range of cases, both in variety and complexity. One day would be spent assisting the more common operations, for example TKR or distal radius ORIF, only to spend the next day on a spinal fusion and osteotomy case that lasted eight hours.

Many patients required input from plastics, orthopaedics and trauma and I would often stay with the same patient for an entire morning and afternoon as they went through respective operations. In my fourth week a gentleman was brought in having been shot during a biker feud. He had been on his bike at the time and had unsurprisingly fallen off post-assault. His shoulder had a large tissue defect from the shot and he had fractured the other wrist in the fall. The plastics team saw him to remove the shrapnel and correct the defect with a double rotation flap; amazingly his tattoos looked as good as new! When this was done, I assisted the orthopaedic team to internally fix his wrist.

As an elective destination The Alfred is ideal for students, offering a variety of learning experiences ranging from high impact RTAs to the more simple but interesting elective orthopaedic work. Melbourne is also a lively city and is suitably located for weekend trips to Sydney, Tasmania or a drive along The Great Ocean Road for some surfing.

Overall I had a brilliant time and wouldn’t hesitate to recommend it to anyone with an interest in orthopaedics, trauma, plastics, intensive care or emergency medicine.

After Melbourne I travelled to Espiritu Santo, one of the larger islands of Vanuatu, in the South Pacific. The health budget for Vanuatu is £10million/year for 250,000 people. They provide a relatively good

standard of care but lack many basic amenities and rely heavily on foreign aid. The locals, or Ni-Van, often come to the hospital as a last resort; they first try prayer and ‘kustom’ medicine before seeking ‘foreign’ medicine.

I joined the surgical team, which comprised one general surgeon and an assistant. Each day was fairly typical; we would start at 8am with general and paediatric ward rounds and begin operating at around 10am. Lunch was usually between 1-3pm once surgery had finished with a clinic running in the afternoon.

I saw a mixture of cases that covered almost all surgical specialties. Despite being a general surgery unit, the team was capable of performing extensive orthopaedic, endocrine or plastic work. However, they lacked the equipment for urological procedures, so any elderly men with BPH had to catch a flight to the main island for their surgery. The government pay for their flight out but not the return leg, resulting in some patients having to stay until they can afford the fare, although no longer with the burden of a catheter bag as hand luggage.

One particular orthopaedic problem I saw during my time there resulted from the particularly archaic practice of bloodletting performed by ‘kustom’ healers on the island of Tanna. Any fractures are first treated with a leaf compress before large cuts are made with a sharp piece of glass over the site of pain. The healer then pushes a finger into the wounds to encourage bleeding and thus removal of the ‘bad blood’ before compressing with mud and more leaves. Whilst I only saw one such case that presented to the hospital quickly, the practise of converting fractures from clean and closed to dirty and open can obviously have disastrous results. I was informed that education sessions are in place, but I wonder if progress is being made fast enough.

As in the UK, diabetes is a growing problem in Vanuatu but the lack of education and appropriate drugs makes treating it an uphill battle and many of the procedures I helped with were complications of the disease. By the end of my time there I was incising, draining and closing smaller abscesses with little assistance and we also performed multiple toe amputations; my most memorable case was a lady who had left her diabetic ulcer for so long that she needed a below knee

BOTA Medical Student Elective Bursary Winner Australia and Vanuatu Joe Lockey

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amputation. They had no power tools so we had to use a Gigli saw to cut through her tibia and leave an end suitable for a prosthesis, should the hospital get some in the future. That experience will stay with me for a long time!

Vanuatu is another superb destination for weekend activities, with diving, snorkelling, blue holes, trekking and beautiful beaches to keep

any traveller entertained. All in all, it was an eye-opening experience and I’d recommend it to anyone interested in surgery within a resource-poor environment.

I am incredibly grateful to the British Orthopaedic Trainees Association for their generous funding.

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Education and Training

Wikipaedics and UKITE 79

An Introduction to Cognitive Simulation 80-81

CCT Guidelines and the Curriculum 82-83

British Orthopaedic Network Environment – BONE 84-85

The Shape of Training Review 86-87

BOTA Position Statement on the Shape of Training 88-91

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The British Orthopaedic Association is soon to launch Wikipaedics (www.wikipaedics.com), an online text and image repository of curriculum based orthopaedic knowledge. Although the Wikipaedics pages will be available to all in the public domain, some material will only be accessible to BOA members. We aim to cater the site to the British practice of orthopaedic and trauma surgery and hope that it becomes a reference tool for trainees and trainers. It will include text, images, video clips, presentations, BOA specialist society publications and guidelines. It will also provide reference and access to some interesting and classic full text journal articles on the subject matter you are revising. The project will be available online soon, initially with trauma, followed by knee and other subspecialties.

The UK and Ireland In-Training Examination (UKITE) portal is also undergoing a transformation and we are planning to integrate the two. BOA members will be able to perform an MCQ/EMQ assessment on the topics they have covered on the Wikipaedics portal. There will be a seamless transition between UKITE and Wikipaedics pages once you have registered to both sites.

To ensure that the information is contemporary with clinical practice and latest evidence we will need a team of editors for each subspecialty to keep pace with the changing orthopaedic practice. We will require active participation from the membership for the Wikipaedics project and would like to receive expression of interest to join the team from enthusiastic individuals at various levels of seniority. We will need a team of 3-4 editors in each subspecialty to drive this and you will be certified appropriately for the work you have done. Apart from the educational value of doing this work it will add to your portfolio for ARCP/Appraisal and revalidation.

Please contact Holly Weldin by email [email protected] if you are interested in becoming an editor for wiki pages.

Annual UKITE examinations have been running in December every year for the last 8 years. Trainees from every deanery now sit this examination. We have had extremely good feedback from the trainees over the years. This year we are changing the platform for the exam to an independent website dedicated to UKITE. We are introducing some upgrades to the exam and editing to simplify the process. It will be available to all trainees through generous funding from Orthopaedic Research UK (ORUK). The new website has improved functionality, updated images and better access from hospital/university computers. Many trainees have requested and availed the facility to sit mock practice exams in preparation for the FRCS (T&O). Our new website will allow access to short practice exams of 15-25 questions on individual topics, or full practice exams. The question submission pages to qualify for the exam have been developed to ease the process of submitting questions and allow addition of images (that do not contain patient identifiable information). Those of you who have previously helped with UKITE will notice that the editing pages will have better access allowing review of the history of your work and also self-certification for your portfolio. As mentioned, we will also be providing custom exams for Wikipaedics through the same log-in via the BOA portal once you have registered with both sites.

You will receive more information about it in due course and we would request that all of you register for the new UKITE web portal.

Like every year we are also recruiting editors for UKITE. Please contact us if you are interested by email to [email protected]

Wikipaedics and UKITEAshwin Kulkarni, Ajay Malviya and Mike Reed

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Since the introduction of the European Working Time Directive (EWTD), the Royal College of Surgeons of England estimates that 400,000 hours of surgical time are lost every month,1 and with this a huge opportunity for training. A Postgraduate Medical Education Training Board (PMETB) survey in December 2009 revealed that a mere 38.1% of trainers felt that they would be able to maintain training standards under the EWTD, while in the same year 66% of trainees felt that their training had deteriorated.2 Even prior to this the father of medicine, Hippocrates, wrote “never before has life been so short, the art so long, opportunity so fleeting, experience so deplorable and judgement so difficult!”. How, with less time for training and the need for an increasingly complex surgical skill-set, can we continue to maintain and improve the standards set by those ahead of us?

Many methods have been proposed to combat this experience deficit, from cadaveric dissection, to the development of life-like synthetic materials, to computer-based virtual reality simulators and multi-million pound reality simulation suites. However all of these techniques share common faults, particularly when considering financial cost; time away from work (for both trainees and trainers); availability of facilities; scope of use and fidelity. In some cases, simulators have even been shown to have a negative impact on performance.3

Cognitive simulation is a mental technique that overcomes these limitations. It is available 24 hours a day, requires no financial sponsorship and can be used for any situation. Based on elements of sports psychology for achieving and maintaining peak performance, it is the multi-sensory creation, or re-creation, of an experience, in the absence of external stimuli.4

Cognitive simulation goes further than just ‘visualising’ an experience, such as an operative procedure, by combining all the sensory modalities to develop the ‘feel’ of it, the sight, the sounds and the movement. Strong evidence from sport supports enhancement of psychomotor skills through mental practice, and it is this area that offers the greatest potential benefit to surgeons.5 In the search for perfection athletes will physically and mentally practice actions hundreds of thousands of times, yet surgeons, whose motor actions are far finer and more varied, do not do so to the same extent, focussing mainly on the practical aspect. It is well established that merely thinking about a movement can generate the same nerve impulses that occur during the action itself, resulting in refinement of synaptic efficiency. Thus, combining the sensory re-creation of a procedure with the kinaesthetics of the requisite actions can have the same effect as actually performing the procedure, becoming a powerful tool in transferring mental practice to physical results via reinforcement of neural pathways.6,7

How does it work?

As with all skills, cognitive simulation requires practice. Initially, making yourself aware of your senses during a procedure is a good starting point; the feeling of the instruments in your hands, the sound of the drill, the smell of cautery. Some people may be able to conjure up these sensations easily, but others may require effort and deliberate practice at first. Beginning with more simple, everyday experiences can help: eating an apple, for example. Close your eyes and recall the smoothness of the skin, the sweet smell, the juicy crunch as you bite into it. Can you taste it?

For trainees, cognitive simulation fits nicely into the step-wise manner in which we learn procedures. Rather than learning from a verbal or written list, vividly recreating each step in your mind with the sensory stimuli, as if you are performing it for real, can dramatically shorten the learning curve.

What is the evidence?

Studies involving medical students and surgeons of all grades have shown a clear benefit of combined mental and physical practice versus physical practice alone in improving the whole quality of performance.8,9 Results from a recent randomised control trial in which participants in the intervention group used a mental ‘script’ with sensory cues for a procedure, showed that blinded assessors rated their performance during the procedure significantly higher than the control group.10 ‘Cognitive walkthrough’ prior to operative procedures can also be of benefit (in the same way that an athlete will imagine their performance before an event), highlighting the practical application of cognitive simulation as both practice and preparation.11 While those considered ‘experts’ use the technique more often and produce qualitatively better imagery,12 frequent practice can help novices develop their imagery ability. Once this has been achieved, not only can you re-create situations to acquire, maintain and improve skills, but new scenarios can be created allowing transfer of skills, correction of errors and more variation in ability. Cognitive simulation can even, through mental readiness and psycho-physiological changes, reduce stress.13,14

An Introduction to Cognitive SimulationDanny Ryan

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Summary

Cognitive simulation (in conjunction with traditional aspects of physical practice) has a wealth of potential benefits in training:3,15 it is free; personalised; can be carried out anywhere; requires no extra facilities; is applicable to any situation; aids with stress management and can improve learning and advancement of skills. As with all tools, the outcomes will only be as good as the application, and it is a method that must be practiced to yield the best results. Fortunately, that practice can be performed anywhere, with a great level of detail.

Psychologically athletes have been ahead of surgical training for years: given the more complex skill-set; the subtler motor control and the high levels of performance required more consistently, it is about time we caught up with their way of thinking.

Danny Ryan is a T&O trainee with a background in experimental psychology. He has competed internationally at fencing for Great Britain, winning numerous titles including British National and University teams and World Medical Championships. This article was prepared with the help of psychologist Uttam Shiralkar , whose book ‘Cognitive Simulation - techniques to enhance surgical skills’, is available through Surgical Psychology Publishing, and sports psychologist Chris Linstead, who works with a number of internationally renowned athletes.

References

1. Royal College of Surgeons of England (2010) Surgery and the European Working Time Directive: Background Briefing.

2. Association of Surgeons in Training (2009) Optimising working hours to provide quality in training and patient safety.

3. Da Cruz JA, Sandy NS, Passerotti CC, Nguyen H, Antunes AA, Dos Reis ST, Dall’Oglio MF, Duarte RJ and Srougi M. Does training laparoscopic skills in a virtual reality simulator improve surgical performance? Journal of Endourology. 2010. 24(11):1845-1849.

4. Shiralkar U. Cognitive Simulation – techniques to enhance surgical skills. 2013. Surgical Psychology Publishing.

5. Suinn R. Body thinking: psychology for Olympic champions. Psychology in sports: methods and applications. 1980. Minnepolis: Burgess. 306-315.

6. Pascual-Leone A, Nguyet D, Cohen LG, Brasil-Neto JP, Cammarota A and Hallett M. Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. Journal of Neurophysiology. 1995. 74(3):1037-1043.

7. Roure R, Collet C, Deschaumes-Molinaro C, Delhomme G, Dettmar A and Vernet-Maury E. Imagery quality estimated by autonomic response is correlated to sporting performance enhancement. Physiology and Behaviour. 1999. 66(1):63-72.

8. Sanders CW, Sadoski M, Bramson R, Wiprud R and Van Walsum K. Comparing the effects of physical practice and mental imagery rehearsal on learning basic surgical skills by medical students. American Journal of Obstetrics and Gynaecology. 2004. 191(5):1811-1814.

9. Sanders CW, Sadoski M, Van Walsum K, Bramson R, Wiprud R and Fossum TW. Learning basic surgical skills with mental imagery: using the simulation centre in the mind. Medical education. 2008. 42(6):607-612.

10. Arora S, Aggarwal R, Sirimanna P, Moran A, Grantcharov T, Kneebone R, Sevdalis N and Darzi A. Mental practice enhances surgical technical skills, a randomized controlled study. Annals of Surgery. 2011. 253(2):265-270.

11. McDonald J, Orlick T and Letts M. Mental readiness in surgeons and its links to performance excellence in surgery. Paediatric Orthopaedics. 1995. 15:691-697.

12. Hall C. Measuring imagery abilities and imagery use. In: Duda J (ed.) Advances in sport and exercise psychology measurement. 1999. West Virginia: Fitness Information Technology 165-172.

13. Arora S, Aggarwal R, Moran A, Sirimanna P, Crochet P, Kneebone RL, Sevdalis N and Darzi A. Mental practice: effective stress management training for novice surgeons. Journal of American College of Surgeons. 2011. 212(2):225-233.

14. Moran A. Cognitive psychology in sport. Psychology of sport and exercise. 2009. 10(4):420-426.

15. Arora S. Surgeons in training may benefit from mental visualization. British Medical Journal. 2013. 346:e8611.

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It appears to me both in my time as a programme director and SAC member, that the guidelines for the award of CCT, along with the associated indicative numbers which were introduced in 2012, have been the source of a considerable amount of concern and anxiety on the part of trainees. They seem to have generated a whole host of questions such as: Will I get my CCT if I have only done so many of…? Or why is…an indicator and not…?

In this article I hope to answer why we have them, why they are what they are, and give an insight into their interpretation and implementation.

The curriculum for trauma and orthopaedics is a long and detailed document which, though important, cannot exactly be described as light reading. As a consequence there are probably few people who have read it cover to cover. Many probably do not even appreciate the difference between a curriculum and a syllabus. The latter is a key part of a curriculum and is simply a list of what you need to know, while the former is a detailed specification including entry requirements, teaching methods, assessments and outcomes of a training programme. It is on this last aspect that this article concentrates.

The statement of outcomes in the curriculum is, in keeping with the nature of the document itself, quite high level. It states, for example, that at the time of the final ARCP a trainee’s portfolio must contain; “evidence of publications and presentations”. In terms of operations the statement reads “…a range and number of operations necessary in order to carry out the duties of the modern T&O surgeon”. The aim therefore of the CCT guidelines and indicative numbers is to

ensure that these statements are interpreted in a consistent manner. This consistency is important not just for maintaining the standards of a CCT and CESR (CP), but also in establishing a standard for entry onto the specialist register through equivalence.

The most frequent comments that I hear in relation to the CCT guidelines relate to the number and range of operations included within the specification for operative experience. The numbers as prescribed in the guidelines are all based on the primary PBAs. In order to be a primary PBA, the PBA has to be assessable and validated, accessible, and indicative. It is the latter 2 of these attributes that are particularly important. They have to relate to procedures which are carried out in sufficient numbers such that a trainee can show progression, and secondly to procedures that are deemed to encompass a range of skills applicable to the generality of T&O surgery. I’m sure at this stage many readers will be saying “okay, but why not also include…”, and it can be hard to disagree with some of the suggested additions. The difficulty here is that while there are many procedures that one might wish to add to the specification, the more hurdles you have to jump, the more likely you are to knock one over. Even with the current relatively limited set of indicative procedures it can be difficult

CCT Guidelines and the CurriculumDavid Large

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to achieve all the numbers, and when that happens it requires a judgement to be made, which brings us right back to the problem of consistency. The fewer the judgements necessary, the greater the consistency.

The SAC recently considered a number of other criteria for inclusion in the specification of operative experience within the guidelines. On the face of it these suggestions were all very sensible, like having an indicative number of cases done as S-TS or greater, and indicative numbers for trauma and elective cases. These proposals were, however, rejected simply because of the complexity they would add, the increased degree of judgement they would lead to, and therefore the reduction in consistency that would result.

Another frequent criticism in relation to the indicative numbers relates to which procedures aggregate into the indicative total. For example, intramedullary fixation of subtrochanteric, shaft, and extra-articular supracondylar fractures all aggregate towards the total for intramedullary nailing, whereas intramedullary fixation of an extracapsular

fracture with a device such as a gamma nail does not. While there would be many who would argue the rights and wrongs of the above example all of these have been considered carefully by the SAC and chosen to reflect the more complex and lower volume set of procedures, a choice which we hope will make the number a better indicator of breadth of experience and competence.

So that is why we have them, and why they are what they are, but perhaps the biggest concern in relation to the guidelines is the question: “what will happen if I haven’t achieved…?”. As I indicated earlier the current number of criteria is such that it can be quite challenging to achieve all the guidelines, and in particular all of the indicative numbers. When the numbers were introduced there was a clear statement that for a time, a degree of leeway would be given interpreting the guidelines for senior trainees. That period has now passed, but there will still be occasions where a degree of judgement is likely to be required. There are, for example, parts of the country where trainees can only get limited

exposure to 1st ray surgery due to cases going to other health care providers, and other parts of the country where local treatment preference favours other treatment modalities over intramedullary nailing. In situations such as these some allowances will have to be made. As with all judgements, they are made on a case-by-case basis and must take into account all the evidence. So, for example, where numbers are low, strong PBA evidence might sway the balance of evidence in favour of letting a low number pass. On the other hand, the same number where there are weaknesses in several other areas might not pass. Whatever the decision, it has to ensure patient safety and be able to withstand public scrutiny.

I hope in writing the above that I have clarified some of the questions that surround the CCT guidelines. They are there to ensure quality and consistency in the standard of CCT. If the recently introduced waypoint assessments are used, along with rigorous ARCP, these guidelines should be reasonably achievable for all.

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The British Orthopaedic Network Environment (BONE) is a free, web-based tool developed by BOTA. It is intended to help trainees, including non-BOTA members, collaborate on audit and research. So, with that sales pitch out of the way–do trainees need to collaborate? Is there a demand for a site like this? Is this going to make your life any easier? BOTA believe that the answer is a resounding ‘yes’!

Trainee doctors have an interesting relationship with audit and research. Every trainee is aware of the requirement to publish 2 peer-reviewed papers, undertake one audit per year and have completed two audit cycles in 6 years (ST3-8). Most of us manage this, although there is often a bit of a scramble to produce a half-hearted audit at the end of every job. But generally speaking we get there, and crank out the numbers.

This is a sad state of affairs. We have a numerical goal rather than a quality threshold. The unintended consequence is that trainees prioritise poor-quality projects:. This is not through laziness or cynicism, but sheer pragmatism. It takes time to plan and conduct a robust, well-designed audit or research project, and the typical trainee does not have the luxury of a full-time research post. Most of us spend 6-12 months in a busy T&O post, trying to do some research for a few hours per week at best, before rotating elsewhere and losing the chance to finish our work.

Yes, there are a few individuals with a natural academic bent who seem to write papers in their sleep, but the rest of us need a bit of help. This is where collaboration comes in handy. Working together has obvious

benefits: we no longer have to have one or two people doing all the work in a short period of time–the burden can be shared, and work can be continued when jobs rotate. More importantly each person can play to their strengths–the senior academic will surely be in a better position to design a top-notch audit of DHS failures, but may not work in a trust with a high turnover. Conversely, junior doctors in smaller units around the country may have an abundance of hip fractures coming through the doors, but limited access to academic support. Thus collaboration can help us achieve both quality and quantity.

Collaborative research networks are not a new idea. Other surgical specialties have been doing this for a while, with great success. There are over a dozen UK trainee-led surgical research groups in general surgery alone, each of which have successfully collaborated on a number of projects. A group of orthopaedic trainees in the North East have taken the initiative to set up CORNET (Collaborative Orthopaedic Research NETwork), a regional collaborative network that has already seen great success in its first year. It is clear that the natural next step is or a national orthopaedic collaboration. BOTA feel very strongly that this needs to be supported, which is why we have been working very closely with Paul Baker, Aashish Gulati and Prof Amar Rangan from the CORNET group during the design and launch of BONE.

We hope that one of the main strengths of BONE is its simplicity. The core of the project is an opt-in member database, open to all trainees, senior doctors, academics and even clinical governance staff from local hospitals. This is tied to a messaging system that lets users

British Orthopaedic Network EnvironmentJamie McConnell

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communicate without sharing email addresses. The user directory can show doctors on your rotation, and can list those who have worked at your hospital in the previous 6 or 12 months, making it easy to keep in touch about previous unfinished projects or future collaborations. A discussion page, allowing people to share their experiences, ask questions and gain help to get projects off the ground, complements this. Together, these features add up to a small communication network for people who are interested in research and audit. Pretty basic stuff so far, but we expect that this will be useful in its own right.

Users can also post information about their projects, with a view to getting colleagues involved (either on a local or national basis). Conversely, you can browse other users’ audit and research and get involved with a project that is already running. Each project posting can contain a set of documents such as a literature search results, protocols, data collection forms, and PowerPoint presentations.

Finally, we provide ready-made audit ‘templates’. These are smaller, simpler projects that users can complete on their own or in collaboration with a few local colleagues. These templates are intended to help you hit the ground running with a well-designed audit where someone else has already done the paperwork for you. We hope that once these templates become widely used, it will be much easier for trainees to produce and complete audit projects in every post. Again, this is not a new idea: the Royal College of Anaesthetists have been providing such ‘recipes’ to their members for years, with great success. We hope BONE will help the world of Orthopaedics catch up in this respect.

The elephant in the room, however, is: what’s in it for the trainee? Will I get my name on PubMed? If you have never been involved in research networks before, you may be surprised to learn that this question has already been solved. Papers that arise from collaborative research can be credited to a Collaborative Group, with the individual collaborators listed in order of contribution. This is a well-established method for giving credit to multiple contributors in a study. All authors listed in this way are still PubMed citable and therefore easily validated by prospective employers when you are applying for jobs. The London Surgical Research Group has an excellent illustration of how this works: http://www.lsrg.co.uk/about-us/how-it-works

The responsibility for each project rests with the lead and person or centre which posted that project to BONE. The idea is that trainees who have well-established audit projects and research studies will register their study on BONE and would be the lead centre for that study. The only people who get their name on the paper are the people who contribute to it. The BOTA committee do not get any credit for your work, unless they directly collaborate with you. We are not here to steal your ideas!

In summary, BONE is simply a tool to facilitate communication and collaboration between trainees. However, we hope and trust that this simple intervention will make a significant impact on the way we work together. We are more than the sum of our parts.

Please take the time to look at www.bone.ac.uk and register to use the website–it is free!–and please get in touch with the committee if you want to know more.

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What is it?

In March 2012 the organisations responsible for medical education and training in the UK asked Professor David Greenaway, the Vice-Chancellor of Nottingham University, to review postgraduate medical training. In particular, the review was asked to consider how this training could meet the changing needs of patients and the NHS, while making sure that doctors remained fit to practice, and able to deliver safe, high-quality, effective care.

The Shape of Training Review has now been published and makes a number of recommendations that could radically change how doctors train in the UK over the next 30 years.

What are the changes?

At present doctors complete a two-year Foundation Programme following qualification from medical school, followed by a 4-8 year period of training in a particular speciality (‘Speciality Training’). As doctors move through their training they are able to practice more independently, and with greater responsibility. They finally gain a ‘Certificate of Completion of Training’ (CCT), and are able to practice independently, within their speciality, either as a GP or consultant.

The Shape of Training Review proposes a number of changes to this system. The key recommendations are:

• Newly qualified doctors will be given ‘full registration’ with the General Medical Council (GMC) at graduation

At present, newly qualified doctors (FY1s) are first given “provisional registration” with the GMC. This imposes certain limits on their practice, and means that their medical school remains responsible for them. After they have been working for a year they gain full registration and progress to FY2. The review suggests trainees should now be given full registration when they graduate but they will be expected to show they are able to work at the appropriate level. The Foundation Programme will continue to take two years.

This change has been proposed because the current system of supervision is fragmented: new doctors are currently supervised from day-to-day by their Trust, but their medical school is ultimately responsible for them. This is a controversial area though, and many have concerns that this move may jeopardise patient safety. It should be noted that this area was not considered in the original scope of the review but was later included after discussion with the Department of Health.

• Speciality training should be much broader and produce “Generalists”

The existing specialties and sub-specialities should be grouped into broad patient care ‘themes’ with common curricula–for example, Obstetrics & Gynaecology, Community Sexual & Reproductive Health, and Maternal & Fetal Medicine could be grouped into ‘Women’s Health’. For an orthopaedic trainee this may look fairly similar to Core Surgical Training, but will probably encourage experience in a wider number of specialities such as ICU, A&E, Plastics, Vascular and Neurosurgery, before focussing solely on trauma and orthopaedic surgery.

Trainees will then train within these broad ‘themes’, rather than necessarily under the old specialties. This change has been proposed because the current system is seen to be producing too many specialists, and not enough generalists. This is considered at odds with the needs of an ageing population who tend to suffer from multiple co-morbidities.

The Shape of Training ReviewPeter Dacombe, Sonia Panchal and Steven Alderson

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• Speciality training should be more flexible

Trainees should be able to transfer freely between specialties within a ‘theme’, with the shared curricula allowing their experience to be recognised. Trainees will also be able to spend a year working in research, leadership, or medical education, and this will count towards their training. This change has been proposed because the current system is seen to be inflexible–both for trainees who wish to change speciality, and for the NHS when planning how services will be delivered.

• Speciality training will be shorter, but not ‘completed’

The current CCT will be replaced with a ‘Certificate of Speciality Training’ (CST). Doctors should be trained to the same level of ability, within a broader ‘themed’ area, but their training should be shorter–taking between 4-6 years, rather than the current 4-8 years.

Sub-specialist training will then be completed post certificate of specialty training (CST) in the form of modules known as “Credentials,” the specific details of this process are not yet clear. This change has been proposed both to acknowledge that a doctor’s learning and professional development are never truly completed, and to ensure that doctors can continue to provide more specialised care, when required.

Who will be affected?

Although the Shape of Training Review only makes recommendations about post-graduate medical education, many of these recommendations are likely to become reality. This will fundamentally reshape medical education for all of us, but will have particular consequences for different groups of trainees:

• Future speciality trainees:

The recommendations will fundamentally change the nature of their training. Trainees will be expected to spend most of their time working within broad general areas of their speciality (for example, general internal medicine) and in a broader range of settings. For trainees who wish to pursue a particularly specialised area of care (for example, interventional cardiology), it is likely that they will need to undertake additional credentials after their CST. Trainees may also be expected to work across different specialties within their theme (for example, geriatric medicine and old-age psychiatry within the theme of ‘elderly care’). Trainees will be able to transfer between specialties more easily, however, should they wish.

• Future foundation trainees:

Besides working in the broader themed areas, and across broader settings, newly qualified doctors (FY1s) may be expected to meet additional competences (for example, prescribing to FY2 standard), given their full registration. They will be able to apply for broader speciality training programmes, however, allowing more time to decide on their career aims.

• Future medical students:

Although the recommendations focus on post-graduate medical training, they are likely to impact on Medical Students as well. Besides completing clinical rotations in the broader themed areas, medical students may be exposed to a wider range of clinical placements (for example, students may complete more placements in the community). Given that new doctors will be given full registration at graduation, medical students may be expected to meet additional curriculum items, and pass additional assessments.

What happens next?

Health Education England has been charged with forming an “Implementation Group” to take forward the recommendations in The Shape of Training Review, and each of the Royal Colleges has been asked to shape how specialty curricular may need to be adapted to incorporate the recommendations. Each of the recommendations has prescribed timescale, and while it is suggested that some take place immediately, most major changes are not expected to take place for 2-5 years. Given that many of the Royal Colleges, and their associated trainee groups have reservations about the report, it remains slightly unclear whether the changes will be implemented at all.

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Background

The Shape of Training (SHoT) report is an independent review by Professor David Greenaway, Vice-Chancellor of the University of Nottingham and Professor of Economics. It sets out a number of recommendations regarding the provision and configuration of postgraduate medical and surgical training for the next 3 decades, with the aim of “securing the future of excellent patient care”. The review has had input from all the major stakeholders including the Royal College of Surgeons of England, the Academy of Royal Colleges and the Academy of Trainees Doctors Group (ATDG). BOTA has identified key recommendations that it supports and also those that it rejects. Trauma and Orthopaedic surgery as a specialty, has always trained surgeons to be capable and competent at providing a general clinical service as well as having subspecialty interests. The FRCS (Tr&Orth) examination and award of a CCT in trauma and orthopaedics supports the notion that a fully trained consultant is competent in delivering an excellent standard of both generalist and subspecialty care for patients. BOTA believe this model could be incorporated into other specialties in order to meet the demands for generalist training in a hospital care setting whilst still enabling doctors to be specialists and providing specialist care. With an increasing demand for musculoskeletal care services due to an ageing population, changes in population demographics such as obesity and an increasing patient’s expectation for a higher quality of life, the ability for trauma and orthopaedic surgeons to be able to manage both the trauma and elective needs of the population will continue to increase. The current trauma and orthopaedic curriculum reflects this need. The current training program has been developed over decades to provide a balance of service and training within the NHS structure, and European working time regulations. Newly appointed consultants who have gained a Certificate of Completion of Training (CCT) through the current training system are able to provide an excellent level of general trauma care having completed the process of competency and experience based learning as well as fulfilling FRCS examination standards.

About BOTA

BOTA is a democratically elected professional committee. It represents trauma and orthopaedic trainees across England, Scotland, Wales and Northern Ireland. BOTA has a current membership of over 1000 Specialty Registrars. Orthopaedic surgeons make up around 40% of the membership of the Royal Colleges and are the largest surgical subspecialty. BOTA are a separate and independent trainee organisation from the Association of Surgeons in Training (ASiT), representing the views of T&O trainees specifically. However, ASiT and BOTA have a very good working relationship, and work together on many issues to represent surgical trainees as a collective. Both the BOTA and ASiT’s response to the SHoT review are similar and the BOTA response is presented below. There are 19 recommendations that have been proposed within the SHoT review. This document reflects the BOTA viewpoint with regard to a number of the recommendations within the review.

Recommendations Supported

i) Recommendation 3: Appropriate organisations must provide clear advice to potential and current medical students about what they should expect from a medical career.

Medical schools should indeed provide a comprehensive and equal standard of career guidance to potential and current medical students. We support a clear and unambiguous delivery of information into how a medical career may progress. This must include a good understanding of the evolving nature of being a doctor, and potential

for fierce competition for training posts. The personal cost of training to become a doctor should be highlighted to take into account the financial and potential emotional sacrifices one may need to take in order to follow certain career paths. BOTA therefore supports the recommendation that clear advice must be provided to medical students about their future career choices and pathways. It is disappointing to note that such a recommendation is still needed.

ii) Recommendation 8: Appropriate organisations, including employers must introduce longer placements for doctors in training to work in teams and with supervisors including putting in place apprenticeship based arrangements.

BOTA support the recognition that a minimum of 6 month placements is needed in order to improve training and continuity of care. Incorporating an apprenticeship model of training is to be encouraged. Despite the limitations of the apprenticeship model, having a specified trainer and team in which a trainee works, benefits the trainee, trainer, the wards and clinics etc. Trainees need “ownership” and a sense of belonging as part of a team and this helps provide the environment for team working and building relationships. This can only lead to improved patient experience and quality of care.

iii) Recommendation 9: Training should be limited to places that provide high quality training and supervision, and that are approved and quality assured by the GMC.

BOTA believes that training should be limited to places that provide high quality training and supervision, and that are approved and quality assured by the GMC. We wholly support this recommendation, training should be limited to places/units that provide high quality training and trainers should be limited to those who demonstrate both enthusiasm and ability to train. Furthermore, BOTA would support any measures designed to help units/trainers improve their training provision. The GMC needs to ensure that such units/trainers are fully supported and that training is incorporated into the employment contracts of trainees with an emphasis placed on trusts to ensure that such training is delivered. BOTA believes that the quality of training directly correlates to the level of service a trainee can provide to patients. Therefore, excellence in training should equate to excellent patient care.

iv) Recommendation 10: Postgraduate training must be structured within broad specialty areas based on patient care themes and defined by common clinical objectives.

BOTA supports the idea that foundation year programs should not have a mix and match set of placements, where a junior doctor may undertake placements in Trauma and Orthopaedics, Psychiatry and Renal medicine for example which is purely down to service provision. Programs should be themed around general medicine, surgery and GP to allow generalist training in the early years with core surgical training being more focused. For example, if a trainee wished to pursue a career in orthopaedics, then a core training post should include placements in appropriate specialties that complement a primary theme, for example: trauma and orthopaedics, Emergency medicine, Plastics, Gen Surgery etc. This ensures that all doctors acquire general competencies in managing patients at FY1 and FY2 level and develop more specific specialty themed competencies based on their specialty career interests.

Recommendations Rejected

BOTA has a number of concerns regarding some or part of the recommendations in the Shape of Training report.

BOTA Position Statement on the Shape of TrainingJeya Palan and Marshall Sangster

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i) Recommendation 5: Full registration should move to the point of graduation from medical school, subject to the necessary legislation being approved by Parliament and provided educational, legal and regulatory measures are in place to assure patients and employers that they doctors are fit to practise.

BOTA has strong reservations regarding the proposal that medical students are fully registered as medical practitioners as soon as they graduate. BOTA support the notion that after graduation, a foundation year 1 doctor should still be on a limited registration in order to demonstrate their ability to work as a doctor in their first year. This should not be changed to a full registration status after graduation. This will be detrimental to patients and pose a risk to patient safety, BOTA remains unconvinced that what students learn in medical school is immediately transferable to the workplace. There is a clear difference between being a student and working in hospital as a doctor.

Furthermore, the erosion of traditional core subjects within medicine such as anatomy and physiology with a greater emphasis on communication skills has led to the development of medical graduates who have better communication skills at the expense of any knowledge of anatomy. This means medical graduates planning on a career in surgery are less well prepared for the rigours of basic and higher surgical training.

ii) Outcome of postgraduate training and the award of a CST rather than a CCT.

BOTA does not support the change from the award of a CCT (Certificate of Completion of Training) to the award of a CST (Certificate of Specialty Training). This assumes that trainees stop learning as soon as they are awarded the CCT but this ignores the concept of Continuing Professional Development (CPD) in which learning extends throughout one’s career in medicine. This, however, is different from being trained and needing to be trained. The CCT should recognise the fact that the trainee has reached a level of skill, knowledge and expertise for that doctor to practice in his or her chosen specialty as a Day 1 consultant. More specialist skills and knowledge is developed through fellowships and courses to support CPD. The CCT and specialty training should recognise this level of training appropriately.

iii) Recommendation 11: Appropriate organisations, working with employers, must review the content of postgraduate curricula, how doctors are assessed and how they progress through training to make sure the postgraduate training structure is fit to deliver broader specialty training that includes generic capabilities, transferable competencies and more patient and employer involvement.

BOTA echo’s the concerns ASiT raised regarding transfer of skills currently acquired in Specialty Training to proposed post-CST credentialing. The Trauma and Orthopaedic curriculum has been devised over a number of years in order to prepare trainees for the FRCS (Tr&Orth) examination and as a competent independent practitioner capable of diagnosing and treating a range of general

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conditions along with selective specialist care for specific patients. Trainees will still have to rotate through subspecialty placements so that they can develop the knowledge and skills required to diagnose any condition that may present and provide treatment where appropriate. Focused generality training over a shorter period will not be able to train a doctor to the same standard. Patients should expect a consultant delivered service, but not at the expense of a poorer quality consultant.

iv) Recommendation 12: All doctors must be able to manage acutely ill patients with multiple co-morbidities within their broad specialty areas, and most doctors will continue to maintain these skills in their future careers.

There seems to be a drive to create “generalists” and not have “specialists”. It remains unclear as to what a generalist is. A “generalist” used to be known as the General Practitioner. In Trauma and Orthopaedics, we are trained to the level of a “general” Trauma and Orthopaedic consultant within the “specialty” of Trauma and Orthopaedics. Trainees receive a broad basis of training in trauma management and elective surgery with the majority of trainees competent to undertake hip and knee replacements etc. Does this report suggest that such a model is still too “specialist”? Certainly in surgical disciplines, there is a clear recognition that patient outcomes are better if the operation is undertaken in a centre with high volumes, by surgeons with more experience in a particular procedure such as THR or TKR. The report states that patients wish to be treated by generalists first and foremost. BOTA would disagree; patients want to be treated by the most competent person available to do the job and that means seeing a surgeon who has expertise in a particular area.

Whilst BOTA recognises that the trend towards “super-specialisation” in the field of General medicine and to some extent, general surgery, has led to difficulties in providing general emergency care cover in general medicine and general surgery, this should not lead to a reduction in the quality of the emergency care being provided in a hospital setting. BOTA would suggest that the Trauma and Orthopaedic model whereby all trainees are trauma competent and trained to the level of being able to provide general emergency trauma care for all patients whilst retaining a subspecialty interest could be used as the model for other specialties. This would require a change in the training curriculum to emphasise more general training including the ability to deal with the most common surgical emergencies prior to trainees developing subspecialty interests. BOTA recognises that patients, especially the elderly, are now presenting with complex medical problems that necessitate a multidisciplinary team approach. It is for this reason that orthogeriatricians and elderly care physicians are an essential part of the overall clinical team looking after such patients and this has led to better patient outcomes and care. The orthogeriatrician is still a “specialist” in the care of elderly patients with complex medical conditions and challenging social needs.

BOTA do not feel the review addresses the different needs of specialists in training. For example the needs of surgical, ophthalmology and medical trainees although similar in a desire to provide the best possible care for NHS patients, differs in their development of knowledge and skills. Surgical skill is currently developed alongside clinical skills. There is no provision of this in the community, and not all surgical skills are easily transferable between surgical specialties. It would not appear to make financial sense to train a future orthopaedic surgeon in the skills required to become an obstetrician or urologist for example. Current simulated surgical skill training has not been proved to provide the same quality of training. Surgical trainees within the current system develop broad based knowledge profile and the surgical skill set to deliver an excellent consultant delivered service.

v) Recommendation 14: Appropriate organisations, including postgraduate research and funding bodies, must support a flexible approach to clinical academic training.

Trainees should be allowed to undertake a higher research degree outside the academic career pathway and this will mean allowing trainees to take an OOPR of up to three years for a PhD or MD etc even if they are not on an academic training programme. This also applies to work undertaken for medical aid overseas etc with such charitable organizations such as World Orthopaedic Concern and the Kenyan Orthopaedic Project. Therefore, BOTA does not support the one-year maximum time limit for gaining other experience.

vi) Recommendation 16: Appropriate organisations, including employers, should develop credentialed programmes for some specialty and all subspecialty training, which will be approved, regulated and quality assured by the GMC.

BOTA opposes the idea of “credentialing” as a way of developing specialists in hospital medicine. In Trauma and Orthopaedics, trainees already undertake fellowships in subspecialty interests in order to get more proficient in certain areas. Often these fellowships are abroad. Who would undertake credentialing and would this be limited to the UK only? How would the GMC accredit fellowships outside the UK and would such centres want the GMC to approve their fellowship posts when competition for such posts is already fierce? This would potentially limit trainees’ abilities to undertake fellowships overseas in world-renowned centres and potentially limit the ability of trainees to bring back to the UK different and better ways of providing the highest surgical care for patients. Furthermore, BOTA has concerns as to who would fund this extra training/credentialing and it is likely that the trainee would have to fund credentialing rather than the hospital trust. How would trainees decide which subspecialty to undertake credentialing in without having been exposed to that specialty beforehand? How would hospitals decide what was the local demand and therefore decide which surgeon to support for credentialing? In any case, there would be a lag time before that surgeon would have completed their “credentialing” leading to a delay in service provision within that subspecialty.

vii) 129. Many of these doctors should be supported and supervised at the level appropriate for their competence and skills similar to doctors in training. They should also be offered opportunities to enter or return to training throughout their careers. They should also be given access to credentialed training.

130. Credentialing will give opportunities to SAS doctors to further develop in their specialty or move into other practice areas.

BOTA acknowledges the very valuable role SAS doctors have played within the NHS. However, we have concerns that enabling SAS doctors to undertake credentialing will create an alternative route for such doctors to gain subspecialty training without the requirement to have passed specialist fellowship examinations. We firmly believe that orthopaedic surgeons should not undertake work as a “specialist” unless they have been through the rigours of passing the FRCS Orth examinations and acquiring their CCT. Removal of this requirement will undermine the role of a consultant in both the eyes of their peers and the public.

Summary

BOTA have fundamental reservations that this is a “back-door” route towards a subconsultant grade of doctor with little influence or recognition and will be the final nail in the coffin of the “consultant”. There is an economic drive to reduce to the cost of training, whilst increasing the number of consultants. The result will be a decrease in

As an orthopaedic trainee, it has been incredibly rewarding to engage in an international masters programme delivered by the renowned Royal London Major Trauma Centre. I have found the knowledge and skills I have gained to be invaluable in my day to day practice and have particularly enjoyed the orthopaedic modules. The online nature of the course means that I can fit it around my work and view lectures whenever it is most convenient for me.Ashley Simpson, Orthopaedic trainee

www.trauma.org/index.php/main/article/1571

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291_14 Joint Journal Ad FAW.indd 1 21/08/2014 17:46

the standard of consultant care. This in the long run will be evidently cheaper for the politicians and also mean that troublesome consultants have little influence on policy. Furthermore, this report is very vague and non-specific and adopts a one-size-fits all approach that is clearly very different depending on the specialty. Patients want well-trained GPs who have a broad range of knowledge and will refer to specialists appropriately and they want to see specialists who are experienced and experts in their field. If certain specialties are struggling to attract trainees, then those specialties should identify why there are barriers to recruitment such as work/life balance and work intensity etc. This report will not lead to better recruitment in such specialties.

The reduction in length of training is not compatible with the high standards of surgical training detailed in the current T&O curriculum. Inevitably this would lead to erosion in surgical experience and capability and a lowering of training standards. Even within the current climate, the effect of EWTR and changes in work pattern to a full shift system has had a detrimental effect on training and any further reduction in training time would only exacerbate this problem. BOTA, whilst recognising and supporting some of the recommendations in the SHoT report, does not support the majority of the recommendations on the principle that such recommendations will lead to the erosion of standards in surgical training and the

introduction of a “sub-consultant” grade of surgeon who is only capable of providing a lower level of surgical care compared to the care provided by the current consultant grade of surgeon. BOTA fully support the principle of consultant delivered care in the NHS and this report will undermine this concept. BOTA believes that this report is a misguided attempt to address the recruitment issues facing certain medical specialties such as Care of the Elderly medicine, Psychiatry and Emergency Medicine and do not believe this will deal with such difficulties.

Finally, BOTA welcomes the reports from other trainee organisations from a breadth of different specialties, which have also highlighted similar concerns regarding the SHoT report. The Academy of Trainees Doctors Group (ATDG) submitted its final report as part of the SHoT review prior to the publication of the SHoT report but unfortunately, most of the conclusions from the ATDG appear to have been ignored. This reflects the strength and depth of unease regarding the implementation of the SHoT recommendations in its entirety that would have detrimental consequences for medical training in the future. BOTA welcomes the opportunity to contribute further to the debate over Shape of Training and believe further dialogue is required prior to any implementation of the SHoT recommendations.

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National Meetings 2014-2015

BSS (British Scoliosis Society) www.britscoliosissoc.org.uk 8-10 October 2014, Bristol

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk 16-17 October 2014, London

BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk 5-7 November 2014, Brighton

SBPR (Society for Back Pain Research) www.sbpr.info 6-7 November 2014, Dublin

BHS (British Hip Society) www.britishhipsociety.com 4-6 March 2015, London

BASK (British Association for Surgery of the Knee) www.baskonline.com 10-11 March 2015, Telford

BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk 12-13 March 2015, Liverpool

BASS (British Association of Spinal Surgeons) www.spinesurgeons. ac.uk 18-20 March 2015, Bath

OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk 19-20 March 2015, Warwick

BLRS (British Limb Reconstruction Society) www.blrs.org.uk 19-20 March 2015, Birmingham

BOTA Deadlines 2014-2015

TOTY 2015 Nominations 21st March 2015

BOTA Junior Essay Prize 2015 – ‘Is 3D Printing, the Future to Picture Perfect Orthopaedic Surgery?’ (800 word limit)

10th December 2014 (result announced 10th January 2015)

Cambridge Orthopaedic Writing Prize 2014 – ‘Healthy Living Sucks’ (must be precisely 1000 words!) 31st December 2014

BOTA ORUK Poster Prize 1st April 2015

Medical Student Elective Bursary 1st December 2014

Dates for the Diary

AO UK

Training & Education for Orthopaedic Surgeons & ORP

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AOTrauma Courses for SurgeonsAOTrauma Course – Hand Fixation Leeds 6 – 8 October 2014

AOTrauma Course – Advanced Principles of Fracture Management Basingstoke 11– 14 November 2014

AOTrauma Course – Basic Principles of Fracture Management Basingstoke 17– 20 November 2014

AOTrauma Course – Basic Principles of Fracture Management Dublin 26 – 29 January 2015

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AOTrauma Course – Advanced Principles of Fracture Management Leeds 23 – 26 June 2015

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AOTrauma Courses for Operating Room PersonnelAOTrauma Course – Basic Principles of Fracture Management Basingstoke 18 – 20 November 2014

AOTrauma Course – Advanced Principles of Fracture Management Dublin 27 – 29 January 2015

AOTrauma Course – Advanced Principles of Fracture Management Leeds 24- 26 June 2015

AOSpine Courses for SurgeonsAOSpine Course – Advances Forum Newcastle 23 – 24 October 2014

AOCMF Courses for SurgeonsAOCMF Course – Distraction Birmingham 20 – 21 October 2014

AOCMF Course – Ballistic Injuries Symposium Birmingham 26 – 27 February 2015

AOCMF Course – Basic Principles in Cranio-maxillofacial Fixation Leeds 6 – 7 May 2015

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