Listen to Sarah Gill and a panel of orthopods discuss their reflections on 2020.
Listen to Sarah Gill and a panel of orthopods discuss their reflections on 2020.
[00:00:00] Festive greetings and welcome to the BJ360 December podcast. My name is Sarah Gill and I'm delighted to be your host. Thank you for joining us either on your commute, a quiet night at work or even some downtime over Christmas and the new year. For news updates and 360 content please follow us on Twitter at BoneJoint360.
This is of course the last podcast of the year, and it seemed like a good opportunity to catch up with colleagues across the UK. So we've compiled a virtual panel of orthopods and asked them for their reflections on the last year, their 2020 vision. We wanted to hear about the lessons that they've learned, what they'd be taking into 2021, be them technical, organizational, or even philosophical.
It feels impossible right now to have a conversation without mentioning the C word. But I promise that the content of this podcast is about innovation and moving forward. And I'm confident that the group of people we've got lined up will bring just that. So please join me as I disturb loads of busy people during the preparation for their festive break and ask them an [00:01:00] impossibly broad question.
I'd like to kick off our podcast this month by dialing in with Tim Coughlin, whose voice will become familiar to you over 2021. Tim is an upper limb trauma surgeon at Queens Medical Centre in Nottingham. He's the orthopaedic undergraduate teacher lead for Notting a medical school, and he's joining the 360 podcast team in the new year.
So it's great to have you on board and to put you to work straight away. When we talked about this episode we wanted to hear from a variety of different perspectives on matters that really spoken to them in 2020. And I think yours is a really interesting one.
Well, so I've been a consultant for just under a year now, and I think there's just a few reflections that I've got over my first year that I think are useful to hear perhaps if you're in your latter stages of training or on fellowship, or if you're in [00:02:00] your first year yourself.
Yeah. Right. Yeah, absolutely.
So, I mean, what I was going to start with is that you spend so long, 20 years probably getting from medical school all the way to that consultant job. And to some degree, you sort of imagine that's going to be an endpoint. You know, it feels like you're there. I guess that's to some degree, the way the trainings designed, but you learn quite quickly that actually nothing has really changed as soon as you become a consultant apart from the level of responsibility you have to take.
And so I remember my first list as a consultant. I had a 3C open distal humerus fracture, and halfway through the case when it's getting tricky, it dawned on me that actually probably for the first time there wasn't someone, you know, in the coffee room or someone keeping a distant eye.
I think, well, it just seems odd to say now, but it's almost an imperceptible layer of protection, which has suddenly disappeared. And, you know, the [00:03:00] case went fine in the end, but I think that, you know, over that following few weeks, I realized that doing all the right things, like picking the right jobs and the latter half of training and, you know, working hard on fellowship, you get all that experience, but actually there's still a load of operations that you've done very little of, or indeed you may never have done, and suddenly people are potentially expecting you to do.
And so I think that one of the key things for me, which I've picked up early on is you have to have a mentor and you have to identify them early on. I think I've been quite lucky, you know, working in a supportive unit and there's more than one person that I can rely on to discuss cases with. But I don't feel any concern now, you know, arranging my list so that if there's something coming up that I know that's on the borderline of what I can do, I arrange someone to be there effectively in the coffee room, you know, a consultant colleague and I've become much more relaxed about just phoning a friend during the operation if I'm not convinced it's the right thing, or if [00:04:00] I'm just not sure, I think that that's fine. That's perhaps not something I'd expected early on, just, you know, you don't really expect that to be the way it was, but that's been my experience. And I think one of the other things is if you don't know who your mentor should be, you've got to ask yourself, who's going to revise this if it all goes horribly wrong? And my advice would be that person's probably the person who should be your mentor. Does that sound fair?
Yeah. Do you know, that's really interesting. Exactly the same, you know, as you say, when you're on the edge of your comfort zone and you are doing something that, as you say, you've been trained to do, you've been told how to do the things, but now you're having to get on and do it. The person whose advice I ask is the person who might inherit it if there's a problem, because then I can think, well, you know, I got their perspective early on and they are usually, as you say, the most helpful person for sure.
And actually, if you ask their advice, you do have to follow it. I think that's another [00:05:00] top tip because that's the person who's going to bail you out. So you do have to take advice when given, I would say.
Yeah, I think that's really like, because obviously we're in the same boat, you know, I started as a consultant in March this year having just left, obviously Queens and still contact those guys for advice by cases and stuff. So yeah, a lot of what you're saying absolutely speaks to me and you realize that the destination is not so much as a destination. It's just another stop on a journey. And that actually.
Yeah. Yeah, exactly.
And you don't suddenly, you know, sort of magic into something else overnight. It is just a progression of where you've been going.
Well, here's to 2021 then.
Yes to 2021, it's going to be a good year.
I mean, I'm excited about it and, you know, as you said, I think all of those realizations come to you in some form or other in the first year. So it was [00:06:00] kinda cool to hear someone else talk about the same things.
I think so and the only other thing I'd like to say is make sure you enjoy it because actually it's easy to get lost in it. And you suddenly realize you're a few months in and actually you just take a breath and you can enjoy it. And I think that it's easy to just get lost in the sort of the, you know, the busy-ness of it, and actually just take a step back and realize that you have achieved something to get there. And you know, that it's an important thing to do.
Do you not think we're all kind of guilty that, you know, you're so sort of task focused, you know, you've got your sort of, you know, you're at the call phase and you're so busy doing that you forget how much you love what you're doing, that you do need to take some like satisfaction and, and as you say, just enjoy the journey along the way. Yeah, I think we're all quite guilty of that and probably the first bit where you spend quite a lot of your time, you know, pretty stressed is maybe the worst time for it. So I think that that's good advice. Good advice to anyone. And definitely, as you say, the guys coming [00:07:00] up to that sort of stage, so thanks for sharing that, Tim. And I'm super excited about you joining the podcast team.
And I'm looking forward to it.
Yeah. Awesome. All right. Well, I will let you get back to, I dunno, making mince pies, right?
Exactly that.
That's awesome, Tim.
Thank you very much Sarah. Thanks.
My next guest is Bilal jamal, who is in fact my friend from work. Bilal works with me at the Queen Elizabeth University Hospital in Glasgow. In another life he was a highly trained foot and ankle surgeon, but let's be honest the main love of his life is all in reconstruction. He's got big frames practice here in Glasgow, and he has been instrumental actually in the development of our post CCT fellowships here at the QE.
He's an all around good guy and I really wanted to get you on Bilal today, get you on the call. So what have you taken away from 2020? What have you learned? What's your 2020 vision?
Thanks for [00:08:00] the invitation Sarah. I suppose I've learned a few things, but one of the things which has perhaps changed my clinical practice the most relates to fracture-related infection. I get a fair few patients who have critical size bone defects and soft tissue defects to go with that as well. And that is usually at least a two stage operation where there's debridement and then the soft tissue coverage and definitive fixation of whatever sort you believe in. But one of the things that we've struggled with is access to theater with redeployment of staff to ICU and so forth.
Yeah. So I suppose we have modulated our practice somewhat and we're going down the route of more one-stage surgery in selected patients.
Interesting. So that is a big departure from normal practice, you know. And there's,I understand, there's a bit of a sparsity really of evidence in literature relating to that. So how have you been able to transition into that? How can you pick winners? How do you pick the patients? [00:09:00] What gives you confidence to say this person is suitable for a single-stage reconstruction?
I think there's a few factors. I think the first thing is that over the past year, for all kinds of reasons, there's a lot more joint orthoplastic operation so that means that you've got a multitude of senior decision makers present at the same time. What we're all doing together is a much better and more aggressive debridement of the fracture and of the soft tissues as well. And then that's probably the most important factor actually. But there are other factors as well. There are some patients, you look at them and you think they are physiologically good specimens, that they have good immune response to the situation and that they have sensitive organisms. And the, I think are guys that will do well with a one-stage operation, but if you don't meet those parameters and I think a two-stage operation remains the gold standard.
That's a really clear message. So basically it's senior decision makers with orthoplastics involved. It's good physiology for patients and it's known organisms.
[00:10:00] Well, that's really interesting. Thank you very much for sharing that with us. I look forward to seeing firsthand how that goes in 2021, you taking that forward. But thanks very much for joining us on the call today and I'll let you get back to your, well, you probably your *inaudible* actually.
Thanks.
Thanks very much Bilal.
Okay. So I'm continuing my round of calls with my next guest and he really needs no introduction. Lyndon Mason was awarded the Huntarian professorship from the Royal College in 2019. And what this man doesn't know about ankle fractures and the posterior malleolus really isn't worth discussing. If you haven't already checked out his BOA lecture, the best gift you can give yourself as Christmas is to do just that.
Professor Mason is the BOFAS outcome committee chairperson elect, and is orthopaedic teacher lead at the University of Liverpool. Lyndon, thank you very much for taking time out of your day to join us on our festive set of phone [00:11:00] calls. I'm really interested to hear about the significant body of work from 2020.
Thank you very much. Your introduction is too kind.
Deliberately so. This is how we butter people up, you know?
So yeah, the biggest body of work for 2020 for us was the UK Falcon audit. It was the largest audit in foot and ankle to date really. And it's been a massive body of work, but it has changed our thinking quite a lot in foot and ankle.
And this is going to be published in 2021. So we're getting a bit of a jump on this.
Yep. Yeah. So this is currently under review in the BJJ and Foot and Ankle Surgery. And then there's going to be a second phase that will be completed in January and we will be looking to publish it after that.
Awesome. If we can get some headlines from somebody, in your own words, [00:12:00] that'd be very interesting.
That is great. Firstly obviously I'd like to acknowledge my co-leads Ajit mangwana from Leicester and Karen Malhotra from Stanmore and also all the participant units. So for me, when the initial COVID surge trial, which is a phenomenal bit of work, was published, we were told that there was a 24% 30-day mortality rate for if you caught it over the time of surgery.
However for me personally, it was really difficult to use that in the consenting process for patients. The patients came in and you give them, well, if you have surgery, that's 25% chance of death. What is the chance of me catching COVID? We didn't know. Also, and this was a ubiquitous across the foot and ankle world really is that you can't really compare a bunyan to a bowel resection for cancer. It is a very different patient. So it didn't really help us [00:13:00] with the *inaudible* process. So what we tried to do is try and find well, what was the instance in foot and ankle surgery and also was the 30-day mortality rates different.
So we had a meeting with...so I was a committee member for BOFAS outcomes committee at the time. We put special interest to all the BOFAS members. Initially we did have about 70 centres that expressed an interest and in the end if 43 actually finally participated and give us the data within that period of time. Some centres were just taking a little bit too long and I think we lost them for that, but we need to get it out too soon because.
So at the end, we actually got 6,644 patients from the time period of January to July and across that entire period, we had 35 cases of peri-operative COVID, which works out as 0.53%. However, [00:14:00] as it was significant time and region variability, for example most regions prior to the UK lockdown in March, that's when they have the peaks.
But some regions, such as the Southeast, which is the worst effected, their peak actually hit mid-lockdown. So if you're only testing certain time periods, you're going to miss cases. Like for example, there was a similar study done in upper limb, by the authors Dean from Oxford. They only used April. Now, if we only use April for our data collection, we would miss about 80% of our cases. So it was quite obvious that different regions peaked at different times.
Down in the Southeast, they are the highest cumulative value of 3% to just over 3%. So 3% of those who are undergoing foot and ankle surgery, caught COVID.
Yes, as you say, massive [00:15:00] regional variation, 3% versus an average of 0.53.
Yeah. And you know, in the peripheries. So...the solar periphery, but I mean, peripheral parts of the UK and Scotland didn't have any cases presented. Northern Ireland didn't have any case presented. Cornwell didn't have any case presented. There was very few cases in Wales. But they all seem to be Southeastern origin and then almost like a band going up through the middle and then up the North West.
Massive body of, you know, national data that you've collected. Was there anything else that you can, you know, were there any other interesting findings in relation to that with the sort of the primary?
Yeah, so we also could see the difference [00:16:00] in trauma practice, elective practice. And we also included diabetic foot and ankle surgery. So the direct foot and ankle surgery. When we found that, obviously the elevtive practice plummeted around lockdown, but the modeling... two papers have been published about modeling, where they actually assumed that we would then get straight back to normal after a period of lockdown. But that obviously didn't occur and you can see this very, very slow trend of trying to increase elective practice when after lockdown the trauma and diabetic surgery returned to normal. We feel it's probably that there was a resource... resources that have been switched from the elective practice to the emergency practices.
The other thing is that... this was one of our primary outcomes, but mortality, we found, was 25% in the COVID-positive [00:17:00] patients. So these 35 patients, it was 25% death rate, which was the same as the COVID trial. So we were no different. So we really shouldn't be seeing ourselves as someone different.
And also the blue and green pathways. There was a trend of less cases in the green pathways, but there was no significant difference statistically. For foot and ankle, it was safer in the green pathway, but it's definitely not safe.
So yeah we have mastered implication actually, in terms of, you know, trying to return, as you said to normal elective services. That is a fascinating piece of work. I look forward to reading about it next year, but it's super to have had you on to talk about that. As you said, a very good example of, you know, large data collection, a large audit, really being able to inform the consenting process around COVID, which has been, you know, one of the very difficult practicalities.
Lyndon. Thank you so much for your time. I will let you get back to your [00:18:00] Christmas cake decorating or whatever it is you've got on at this time of year. But thank you for joining us and I hope to speak again on the podcast next year.
Thank you very much. Thank you for the invite. It was very kind of you.
Thanks now. Take care.
I would like to welcome John Phillips from the knee units at the Royal Devon Exeter Hospital to the podcast. John contributes to both the oder and beyond compliance committees. He's a member of BASK faculty and also the BJ360 editorial team. So I'm excited to hear his perspective, his knee arthroplasty perspective, going into 2021. John. Thanks very much for joining us.
Well, thanks Sarah. So COVID has had a huge impact on our life and work. And there are a number of obvious ways impacted, but one of the positive ways is it's given myself and my colleagues who work on the revision, the working group time to put [00:19:00] together some guidelines on how revision knee surgery in the UK can be restructured.
This is a group put together, led by one of my colleagues in Exeter. And it's something we've been working on for a few years and basically revision knee surgery in the UK. It just wasn't really functioning terribly well. It wasn't ideal. Outcomes revision knee surgery, certainly survival outcomes after infection are actually worse than most cancers.
So this has led to a number of initiatives, but largely trying to work out how to restructure surgery. And it's largely based on a sort of hub and spoke model led by NDT. So that that collaboration of surgeons is encouraged. And low volume surgeons have basically, you know, stopped doing surgery and so the minimum numbers have come in for a minimum of 15 revision knee operations per year for [00:20:00] surgeons who are keen to perform revision knee surgery and unit volumes of 30 a year.
And like I said, it largely follows an MDT approach and there are a number of audit metrics that are going to be used to sort of monitor performance such as length of stay, such as mortality infection rates. And other subjects such as numbers that have run through the MDT, numbers performed in each unit and also the amount of loan kits used.
Yeah. Do you know that's really interesting, John, because I know when we've spoken about it before you likened it to sort of the MTC approach. Suppose that this process will go through the sort of learning curves that we did, you know, eight, 10 years ago with MTC work. If people want to read more about this and things, where can they look for more information about the work that you guys are doing?
So, yeah, correct. Good point. The worry is, or one of the thoughts is that the larger centres may be overwhelmed at work, but that's not to be encouraged. What we're trying to do [00:21:00] is to make sure the most complex work that's done in the larger centres, but actually the revision knee work is spread amongst surgeons who are keen and interested in well-trained and are good at doing it.
So we've put together a number of articles. There are three boasts in revision knee surgery. One for, sort of planning of services and other for infection, the other for investigation of problematic knee replacements. And they're freely available on the BOA website.
And as a group, we also put together and I hope that it's the, a number of articles that are now published in the Knee journal that discuss all the aspects of a revision knee surgery, but this is all sort of acumulating in a good practice guidelines that should be coming out in early 2021.
John. Thanks so much for joining us. That's really interesting. I'm really looking forward to seeing what comes out with that and the discussions, especially as you said, you know, the discussions around centralization, but actually what more, sounds like a genuine reorganization of services. Yeah, very excited to see what comes with that. And thank you so [00:22:00] much for your time. I'm sure you've got a ton of Christmas wrapping to do so I'll let you get back to that.
That's great to speak to you.
Merry Christmas.
Merry Christmas, take care now.
So I've got a confession to make here because I really would use any excuse to speak to our next podcast guest on the basis, that I always feel more knowledgeable after speaking to him, I thought he'd be excellent value to get him onto our BJ360 festive podcast.
Dan Forward is an orthopaedic major trauma consultant in Queens Medical Center in Nottingham with a particular interest in pelvic non-union and complex periarticular trauma. And also I know in *inaudible*. So Dan, thank you very much for joining us and what top technical tips can you share from 2020?
Oh, hi Sarah. Yeah. So I've got three thoughts on fracture reduction. So in my mind, yeah, everything's [00:23:00] about making it as easy as we can. And generally speaking, if I can get the thing reduced and it'll just sit there for me while I lay some plates on, that's gotta be the best bet.
So the first one I learned in fact from my colleague Mark Patton, who's an excellent surgeon. So this is femoral fractures now. And if you're going to have to plate it for whatever reason, I totally accept some people love a retrograde nail. If we're thinking about plating a distal femur, then actually we always reach for the traction table. So put them up, like it's the DHS for the other leg. And then on the fractured leg, actually leave the support in underneath, put on the traction like you normally would, dragging it straight out. You can adjust the varus valgus a little bit with the direction of the pull on the traction table and in general, it will actually just distract things nicely back into a pretty neat position that is well aligned up with no one doing anything. Occasionally you need a [00:24:00] bag of saline under the knee, if there's any sense of extension in the distal piece and just positioning that neatly wall to prevent that happening. And then essentially you've got a leg that's straight, reduced, easy to take x-rays with because the machine will come in, like it would for DHS that you can spin through the lateral and get the AP without any problems.
You're not relying on the registrar, trying to remain strong and engaged during an operation that they'll otherwise might be board in. And the whole thing will just play out really quite neatly for you. You can use the usual DHS shower curtain or nailing drape again, to keep things simple. And generally I just use a small incision deciliter instead of the plate in and then a couple of incisions up the leg for the proximal screws. And you end up with what can be a difficult operation, I would say rendered pretty easy.
Yeah, absolutely. So Christmas present for you because everything's reduced. Christmas present for the registrars [00:25:00] who are not, *inaudible* off the table.
Exactly. So just makes it, yeah, what can be a difficult operation, pretty simple.
That is an awesome top tip. Give us your second one then .
A second one, other side of the knees. So proximal tibia now. Yeah, so I'm thinking here kind of Schatzker six type injuries rather than necessarily a simple two let's say. So yeah, for those then I like to construct a little quad frame before I start. So I would do my usual lateral approach to the proximal tibia and then put a pin through the epicondyles of the distal femur using the wound I've already made. So that's a bar or pin now going through the distal femur. And I'll put another one through and through the mid shaft tibia. So low enough down that I can proper plate it without any problems. And then on either side of those two transverse pins, [00:26:00] I connect up my extrix bars, common obviously radiolucent wont get in the way of the x-rays. And then some of the systems have these neat little jacks that you can essentially link them, the tibia, away from the knee on both sides now. So you've got independent and control of the medial and lateral rod. So you can gain lenght if you lengthen both of them or change your angulation, if you just lengthen one of them relative to the other.
So essentially you start off again with a short kind of impacted stratica six sticks type situation that you then gradually lengthen into a pretty well-reduced correctly aligned fracture. I do all this with the leg completely flat, straight, on a carbon table. And in general, it all lines up seriously well that you end up just laying on some plates.
Yeah.
Either one lateral plate or perhaps a lateral and a [00:27:00] medial, depending on how you feel the stability of the fracture is. Ultimately you start the operation after perhaps 10 minutes of constructing this with what is essentially an undisplaced fracture now, other than a little bit of minor adjustment around the edge. So again, turns what can be a complex operation into a pretty simple effect.
That is a really neat idea. And, well, I don't know, somewhat embarrassed this hasn't occurred to me at all. This is not my experience with Schatzker six, but yeah, definitely looking forward to giving that one a go, actually. I'll send you some pictures.
Nice. And then I understand this is a recent...this is hot off the press, this last tip.
Yes to hot off the press this one. And particularly genius, I like to think. So this, I'm thinking now, so fracture, you know, typically, so this is the kind of one that in my mind is still on the x-ray film of the ankle. So low enough down that you are going to plate [00:28:00] it and they accept that some people might say, well, I just put screws in here or whatever, actually fine, but here's one that I'm plating.
So, in general the distal bit of the fibrillar tends to drift out laterally as part of the fracture complex. And so, yeah, for me, I'm going to open that up and plate it. And, the registrars often try and get these things reduced before they even start, which is kind of what I've expounded for my distal femur and proximal tibia. But actually here often it's quite a struggle to get these reduced and to stay there. And actually what I would tend to do is put my plates on from proximal to distal. So let's imagine a pretty transverse C I'm going to start screwing it from proximal to distal, and it will tend to buttress in the lateral displacement of the distal fibula to start the reduction and generally you get a pretty good reduction out of that without even trying. These are aligned now. Most of it is sitting in the right place. [00:29:00] But obviously the worry is with how much length you've gotten and needing to be sure you're not short. So my tip here is in the way that the classic AO pitfall, I guess, is trying to compress through a plate then using the wrong end of the hole. And there's the, you know, the classic AO x-ray of a fracture distracted because you stuffed up to help the guys understand that you need to have the drill away from the fracture to get your compression.
So actually here, I'm advocating doing the opposite. So actually eccentrically drill close to the fracture. And as your screw goes in, you'll just get that little bit of extra length out of it to ensure you're not short. And so counter-intuitively using the wrong end of the whole, actually here is going to benefit your reduction. And yeah so that's my final tip for 2020.
So for the foot and ankle surgeons listening here, we're talking about pronation abduction [00:30:00] injuries where you've got that comminution, length is difficult, as you say to achieve and then, you know, pre-plate fixation. So by essentrically drilling the holes in the distal end of the plate, close to the fracture, you can dial in that length. And presumably actually, you could do it with one hole for a bit more length for it. You could actually even do it with a second hole needing to remove that first screw to get a little bit more.
Yeah, exactly. So what some people advocate using, for example, a screw outside, so fixing distal first, screw outside the plates at the top, laminate spread or that kind of thing to dialing their link through that. And again, great tip. Absolutely. Yeah. It's got its place for sure. There's difficult with that sometimes is your distal plates not quite right, you're stretching it out and actually it starts to angulate while you're doing that, because the amount of control you've got is relatively limited. So, it's just a different approach to that really. So rather than using that kind of thing with longer wounds at the top, and the problems coming to you from the [00:31:00] nerve and exposure is actually doing it the other way round instead. I think it gives you better control. But as you say, if you need more and more lengths, you could do it more than once.
Yeah. Great. Adjunct.
That is yeah. Okay. So that's the Gill modification of the forward technique just for future reference. Some of the time it works all of the time. Dan as always awesome value, great views. Thank you very much for sharing those things. And I'll let you get back to your chicken farming, festive preparations.
Brilliant. Thanks. Good to speak to you.
My next guest on our festive podcast is Phil Johnson from Addenbrooke's hospital in Cambridge. Phil is a hand, upper limb and trauma surgeon and is faculty on both the BSSH and AO [00:32:00] trauma instructional courses, and including being the AO Principal's chair. So Phil, thank you very much for taking the time to join us on the BJ360 festive podcast. And I'm very interested to hear your reflections on practicing in 2020.
Yeah, thank you very much for the invitation. So it's been a really weird year. And the things I've taken away from it really have been this advent of virtual working and prioritization in orthopaedics. We see ourselves being furloughed. We've seen arthroplasty colleagues aren't able to work because we can't ring fence beds because the beds are full of patients with illnesses, coronavirus and other things. And so arthroplasty has gone more or less out the window, and we've tried to start again over the Summer and the Autumn and we've been stopped again, but in place of that, the arthroplasty colleagues and the people with their elective sessions emptied have been doing great things. So they've been going to A&E and at the front door, helping with the minor injuries, helping with orthopaedic problems in particular and streamlining A&E.
And so we've seen virtual fracture clinics, [00:33:00] referrals dropping because people are dealt with at the front door and rerouted and diverted and getting definitive treatment and triaged at the door. So we already had a virtual clinic, which kind of reduced our footfall by perhaps a third, but we're now reducing that referall to virtual and to fracture clinic even further through having people at the front door, making those decisions.
Yeah, that is... do you know... I'm really glad actually, you came in and spoken about that. I think that is definitely an experience that I have seen in Glasgow. That's exactly what happened in our unit as well. As you said, it's a further layer of filter in terms of early decision-making with reduced referrals into the virtual clinic, because in fact the treatment has already started.
There's obviously also been issues with access to theatre. And, you know, I'm interested to hear your reflections on that, particularly as an upper limb surgeon, because of course the neck of femur fractures, the non-ambulatory trauma has to come into the hospital, but big changes in terms of upper limb injuries. [00:34:00] Give me your thoughts about that. What have you seen? Any issues? Would it change what you do in 2021?
Yes, I think so. So upper limb surgeons are notoriously conservative in their treatment plans. We've had trials showing us we should be doing less, some trials on shoulder fractures showing people doing nothing and then risk fracture trials showing we should be worrying about plating and my practice has already moved towards the conservative, but this first three months of March, April, May, and early June, we really had very little access to theatre for that kind of standard day-case upper limb fracture. And so we had to be very critical over what we referred to theatre. And so we were treating things more conservatively through being forced to do this and yet the outcomes have not crashed. We haven't seen much worse malunions or nonunions of scaphoid. Malunion of distal radius and therefore, probably we are operating too often. Perhaps we've been forced to operate less often and haven't seen a car crash as a result.
Yeah, so we had this conversation cause [00:35:00] we were like, we're going to have this avalanche of non-unions, mal-unions and you know, painful risks in the Autumn, which never seems to have arrived. The only caveat I would say to that is, do you think that that is on the back of a significant front door investment that people have been able to make? Do you think in 2021 should the theatre side fall down, but you know, we have less orthopaedic input at the front door or do you think there'll be... you will see something different?
It'd be hard to say that the orthopaedic consultant was better than the practitioner in ED for manipulating fractures. But I think we deployed a little mini C-arm to help us. And we do have some skilled people giving good manipulations at the front door. So perhaps that made a difference and we were perhaps more confident that the wrist fracture wasn't going to fall off in the first couple of weeks requiring intervention in theatre.
So that was probably true which just shows that really, if you get the right people to do the right thing at the right time, you can minimize your requirement [00:36:00] for theatre. And that's better for everybody. A few complications and it's cheaper for the NHS as well, so there you may be front-loading it and may be good beyond that.
Do you know, getting it right first time, Phil, you should, you know, that's an idea we should do that.
Absolutely.
Yeah, I think, as I said, really interesting to hear your reflections on that. Definitely echoes some of my experience and sort of summarizes, you know, articulates that really well. And I think is, you know, something positive out of this year is that we can be brave in terms of our reform of what we do. Just because we've already done it one way doesn't mean we have to continue.
We've been forced into virtual working and we've all become experts in Zoom and StarLeaf and Teams and all the other various online media, but patients don't mind. And in fact, we've reduced the handling by at least a half in terms of footfall to clinic. So the number of telephone consultations we're doing has gone up and the number of [00:37:00] people turning up has really, really reduced. And patients are happy. They're saving themselves time. They're being seen at some point in their pathway, but they're being referred for tests, either having a telephone review with the results or being seen after telephone triage at the start.
We are definitely streamlining the service and we're reducing the number of people coming to hospital by necessity. And that's a great thing for everybody. Patients are also much more aware of what they need to have done and they're pulling stuff off of it just doesn't need it.
And it is also, you know, I think it's more respectful of patient time as well. You know, we're not having these hugely overpopulated fracture clinics where people wait around for hours to get an x-ray that actually, you know, you might have said is not really going to change their management at this time, bill. Phil thank you very much for summarizing that so nicely and sharing that with the podcast listeners. I hope you get some good time off over Christmas and all the best for 2021 when we catch up then.
Thank you very much.
Merry Christmas. Thank [00:38:00] you.
Welcome to our next caller, Vitti Bucknall, orthopaedic paediatric surgeon Alder Hey Hospital, and I should declare my conflict of interest cause she is also an excellent friend of mine, as a fellow Scottish training graduate, actually. So Vitti trained in the Southeast of Scotland before being, yeah, I'm going to say stolen, south of the border for her consultant posts this year. Vitti was a previous BOTA president. She serves on the subspecialty board for Trauma and Orthopaedics at the Edinburgh college, and she is a newly elected regional SAC representative. So congratulations, there Vitti. So yeah, someone with something to say, and I have to say always worth listening to, so thank you very much for taking time out to join us on our festive podcast.
No. Thank you very much for having me.
So polite. So tell us [00:39:00] about, same question. What's your 2020 vision? How is it going to affect your 2021?
So for me, some of the lessons that have come from 2020, as for many people, has been... really the most important lesson is looking after your team and keeping a team together, because having a fantastic team around you is absolutely invaluable. And COVID this year has certainly shook that for a lot of people.
Yeah. And you know that, as you say, that has been a challenge. I think in, you know, all walks of life, work very much included. Tell us about your experience of that. Like, you know, what were the, like, can you sort of, what were the specifics of that and how did you deal with it?
Yeah, sure. I mean, I came down here as a fellow. What struck me first and foremost for all the hate was the orthopaedic team and how amazingly cohesive the team is. You know, having coffees together, having lunches together, people [00:40:00] helping each other out.
You cant pitch for jobs Vitti... you can't, you can't use this as a...
Jobs are all taken...
However, you know, with COVID coming along, it can really shake even the most, the strongest of teams. So for me, seeing how that has challenged our team is when we realize that going forward, that's something that needs to be nurtured, just like any other relationship. So, I suppose as an example for COVID we were artificially split into team A and team B. Team A were at home while team B worked to protect each other. And through doing that communications were immediately stumted. And then even when you were at work with one of your sides of the teams, the coffee areas were shut, we couldn't go out for our curries. You know, you can't grab a drink after work so that, you know, not only the formal, but the informal chat that we have that keeps us younger, that keeps us talking that makes us have each other's [00:41:00] backs. That was no longer there.
So, I mean, we did find other ways of getting around this by having Zoom beer nights, so beer tastings. We recently had an away day for the orthopaedic team, which wasn't exactly very far away. It was just outside the education centre, but it's an opportunity to sit down as a group, have some pizza and talk about the problems that we're currently facing. us in 2021.
Yeah, that's awesome actually. That, as you say, it's sometimes one of the things you don't know what you've got until it's gone and you've got a tight knit team and lots of informal communication. Yeah. There is a very physical barrier to that this year for sure. So tell us about 2021. Like, you know, is this going to change the way you do stuff?
Absolutely. I mean, obviously we want what we had before. We want our Christmas nights back, we want our summer nights back. But it's really taught us that having dates in the diaries time to put aside for our work family.
So having those dates in the diary going forwards [00:42:00] are points that we'll all make an effort to attend to be there but also include some of our fellows having a fellow alumni. So building upon knowing that having a team is important, we just got to nurture that even more and grow all the Haven. So the message is, dates in the diary.
Dates in the diary, get it in the diary, get your set, get it sorted. Look after the people around you because by God do they look after you.
Well, so my take home message from this are, keep an eye out for job adverts at Alder Hey. Get some dates in the diary, get some zoom beers on. Vitty thanks so much for sharing that, as always positive as always. And I've interrupted you on call so I will let you get back to back to that. But when you get a break, please do enjoy your Christmas and yeah, Merry Christmas Ross.
Merry Christmas from Alder Hey. Bye [00:43:00] now.
I'm very grateful to our next guest for joining us on the BJ360 festive podcast. Havin Singh is a consultant, upper limb and trauma surgeon at Leicester Royal Infirmary and Leicester General Hospital with a PhD in health sciences, professor Singh. Thank you very much for making time to join us. And I'm really interested to hear about some of the research he wanted to talk about that has come out of the circumstances this year.
Thank you, Sarah for this opportunity. It's been, you know, COVID-19 pandemic has been a situation of lifetime, but I think there are some opportunities in it. One of the key things that I'm interested in is how to include virtual assessments of these patients. Being a shoulder surgeon, you know, the technology's already there. Like if you look at the newer iPads, which are coming out, they've got lighter technology already in there. So my research is focused on how [00:44:00] we can use the patient's smart phones to assess their shoulder range of movements and their limitations. So the markers are not required. We just virtually assessed them sitting at the end of the phone or an iPad. And you can look at the range of motion and this is going to be, you know, validated by Vicon camera's in Cambridge university. So this technology has been developed and we assess them and we compare it with the Vicon cameras. So it should be quite interesting how this pans out in the future.
That sounds really promising. I've got to say it's one of the conversations that comes up with colleagues in terms of what can we do safely, virtually, and what do patients have to come to see us about? And obviously imaging is something that brings them to hospital. But, one of the things that I always thought would mean that people need to come to hospital is a physical assessment, but this is actually something that you're saying we can accurately do in terms of range of movement. A lot of [00:45:00] shoulder pathologies can be safely assessed from home now.
It is a product which is in development, but a lot of these assessments can be done virtually with use of prompts and patient questionnaires. And in addition, we can have these virtual assessments through cameras. We can look at the problems, but you know, it is a segmental problem most of the time. If you understand, the frozen shoulder will have a limitation in a certain range and then we'll have limitation in a certain range and these can be virtually picked up, but this needs to be developed further.
What sort of technological know how will the patient need to have in order to be able to engage with these assessments?
So, they should be able to use their smartphones. They don't have to use any technology on it. There'll be given access to an app, which they can log in and that will allow us to virtually assess them, just [00:46:00] through the app.
You know, this technology is already being used by hearing services. They can virtually adjust all the hearing aids through their apps. And I think this can be, this has a big role in other fields also. So that's why we're looking into shoulder pathologies and how we can assess them virtually.
I think being able to, you know, virtually assess patients, especially a patient population that you might not want to be coming into hospital in these times. But being able to continue to deliver their care. That's very exciting. And, I really look forward to maybe seeing some more stuff about that in 2021. I look forward to you publishing.
Thank you very much.
Well, look, thank you so much for taking time out of everyone's busy week and in the run up to Christmas. So from everyone at the BJ360 have a very nice break. I'm hoping you're not working all the time, and catch up in 2021.
Thank you, Sarah.
Thank you so much.
What an interesting call there with Professor Singh. Another [00:47:00] example, or proof rather, that necessity really is the mother of invention. And a further example of innovation coming out of this strange 2020 year. I'm kind of interested to see not only how yeah that virtual assessment can play a role in patients preoperative workup and initial consultations, but also maybe the application to follow up and the collection of accurate examination findings that could augment, you know, research without the patient needing to come into the hospital.
So thank you to Professor Singh again for joining us for that call.
So continuing on, with our festive jaunt through the callers today. We are joined next actually by a familiar voice in UK orthopaedics. Mark Baldich is a knee surgeon in Ipswich and Colchester. Having served as a previous trustee council and committee member, Mark is [00:48:00] the BOA treasurer. He's also the current head of school of surgery in east of England having previously been an SCC chair.
So, as a man with an eye for the bigger picture, I'm really interested to hear your reflections on 2020 Mark and where we're headed.
Good evening, Sarah, and thanks very much for asking me to speak to you tonight.
So my reflections this year have been, like many on many topics, but one of the main issues in orthopaedics is that if we have no training for future surgeons then we will not have any surgeons for the future. I'm sure you've been aware of the stark data that's come out of the JCST and the log books but elective training has really fallen off a cliff since the first lockdown. And that is a real problem. And it's reignited my wish to try [00:49:00] and take every single opportunity, maximize every training opportunity that's available, whether it's in clinic, whether it's in the ward, whether it's just walking around the hospital to discuss and make every opportunity I have with the trainee and training one.
It's one of those things. It's been a, as you say there's been... the change in system over COVID has been, you know, it's, it's, it's obvious the detrimental effect it's had in terms of elective training. It's been a bit of a depressing time and therefore it's kind of nice to speak to you and hear, you know, actually this is a time for re-ignition of passion about training. Not sort of everything is a bit difficult. But it's actually more, what can I do about that?
It's difficult because there's a lot of pressure to clear the backlog of waiting lists. But unless we take the opportunity to make sure that we can give these opportunities across to our trainees then roll forward. We wouldn't have any surgeons [00:50:00] for tomorrow.
I should say that that Mark is joining us after a busy list in the private sector, well in private hospital and there's been training going on today. So this is sort of in action. So give us a sort of, an idea of how you, what have you been doing to get those training opportunities into your day to day practice?
So as part of my role of head of school, we've been very keen at least in England to ensure that any work is lifted and shifted to the independent sector, such as my list today. The trainee comes too. So that's part of the memorandum of understanding that we have with the lift and shift and in order to do that, it takes quite a bit of preparation. But it's absolutely essential.
So that's the sort of background. And then on the day, have to have an agreement with the team, with the anaesthetists, with the scrub team, at the huddle we [00:51:00] decide which cases the trainee is going to do. We agree that the trainee is going to do at least 60 to 70% of the list. Three out of four cases, if possible, we choose them, we've discussed them beforehand and all members of the staff recognize that even if it's at four o'clock, we've got a case to go, then I might do that last case so that they're not edging and hassling to say consultant, lets do it.
So it is about teamwork and about an agreement or sort of contract between the whole team that there's an understanding that we're here to train trainee and if they don't get the opportunities, then they won't progress.
You know, you clearly are leading that. You're leading that conversation and you're engaging the theatre team and those around you in clarifying that this is an important part of the day is the training of our future surgeons.
Some people will be listening to this and thinking I'm worried I might encounter [00:52:00] resistance with that conversation. Have you encountered any resistance and if so, how did you deal with that?
Well, I think, no one likes to overrun. So you have to plan your list. Plan it with the extra time training might require. And if you don't do that, then you you'll end up upsetting people and they'll be more resistant next time.
It helped today because I brought presents for the whole team. So I landed that with them early on in the huddle at the beginning of the day. And of course everybody was happy.
Yeah, you're right. Very difficult to a very, very difficult to provide resistance when provided with a bottle of wine. Yeah, exactly. So there you go. So trainers and in fact trainees turn up to the huddle, having stopped at Sainsburys beforehand.
Well, Mark, thank you very much, honestly, in what has clearly been a very busy day and [00:53:00] very productive day. Thank you for dropping in at the BJ360 festive podcast.
Going forward, I think if we're waiting for this to stop in order to start restart training, we will lose a significant amount of training.
Absolutely. And I find that the trainees bring a huge amount at the day. They help educate me on lots of things and it's a really invigorating experience. So I will rue the day, if we don't have trainees.
Having made everyone else do the heavy lifting and supplying the content for this podcast episode, I thought it was time that I made a contribution and we've heard on a variety of themes from my notes, organizational change, research, training, clinical decision-making technical tips. And I want to pull together some of these themes and offer up a couple of things that were parts of my orthopaedic 2020.
[00:54:00] The first topic that I wanted to offer up is a combo of technical tip and teaching because 2020 has definitely been the year of the zoom teaching session, which is great because it's meant that at time, when the training has been really squeezed trainees have had access to learning from a wider pool of trainers than otherwise would have been possible.
And a topic that often seems to come up, both in requests for formal teaching and on a day-to-day basis with trainees is pelvic fractures, particularly pelvic ring fractures, because I think trainees suspect that they're more likely to come up in FRCS than acetabular fractures. And I think it also reflects that pelvic fractures in general are not always hugely well covered in preceding training.
And I'm not going to attempt to summarize pelvic fractures in two minutes, but what I have is a very specific tip or concept that seems to resonate well with trainees.
This relates to both manipulating CT reconstructions, preoperatively, and deciding what you're looking at and what views you might [00:55:00] need interoptively.
So my useful nugget is that the pelvis is a composite structure. So an AP pelvis is actually a view of nothing and all the other views like inlet, outlet, et cetera, are in fact APS, laterals, and axials of the structures making up the pelvis ring. So extrapolating that my tip is don't fixate on rote learning, what views you need, but move from prescriptive to intuitive approach towards pelvic imaging interpretation.
So for example, the pelvic view is actually an AP view and the in the view is the axial view of the pelvic ring. And it can be censored on whatever parts of the ring is of interest. Be at the back at the sacrum, the whole pelvic ring or the front of the pubis.
So when considering the ileocecal corridor, you need an inlet view to show you the front to back position of your wire or screw. And you need an outlet to show you your [00:56:00] superior inferior position. When considering the suprascapular coder and inlet and slightly oblique or that down the wing will give you an axial view of that super acetabular corridor. Whereas an outlet opterator oblique will give you an AP of the corridor. You can apply this concept to any part of the pelvic ring.
And obviously all the trainees listening will have asked father Christmas for a pelvic shore bone for Christmas, but alternatively, you would be able to find one in theatres. So sit down and work your way through this idea and talk it through with your local pelvic surgeon.
And the second thing that I want to talk about is collaborative research. And look, I know this isn't new to 2020, but I wanted to give it some air time because I think there's a type of clinical collaborative that's really picked up the piece this year. Published research on this topic from 10 years ago showed that fewer papers were published from orthopaedic collaborative research to these than any of the surgical specialty. Now, of course, this has changed because of the multicentre pragmatic trials that [00:57:00] are booming.
Draft UKAF or a fixed ET. And then we've got wax and soft trials. The list is impressive and growing. And the data of these trials collates lends itself to heterogenicity and wider relevance. They've replaced the single centre cohort studies and the single surgeon in my hands research and their science and inclusive nature lend them to addressing the bigger question.
Now, this is a personal opinion, but what these trials gain in breadth, they have to like in fine-grain detail. They shape my practice broadly, but I don't think they helped with my clinical decision making on a case by case basis or that they help me advise the patient in front of me in clinic. And I'm happy to debate this in future, but I think I'm always going to find well-designed RCTs or cohorts studies are valuable for that.
So I'm really encouraged by the increased output of existing multicentre collaboratives and the formations of new ones in the last year. I think it's a real comment and a real [00:58:00] strength of our collective psyche that in times of uncertainty we've looked to work together, we've read the work coming from the IMPACT study group and others elsewhere in the UK. And I think it's very exciting to see this enthusiasm.
My experience of contributing to collaborative research this year is that you're able to answer a question in a more robust way with a bigger data set that's more representative. You're able to refine your research question because two heads are better than one, but it still allows for scientific rigour and type data collection. It means you can answer detailed clinical question despite limited numbers in any one individual centre.
And there's the hidden benefits such as pooling enthusiasm and resources that helps you get the work don. So my take home message when I think about research questions now is I just ask myself, would this be better answered with more numbers or wider population or do I actually need help in terms of study design? And if the answer is yes, I'm going to present it to the research collaborative. And if you're listening to this and thinking, well, I'm not in one, then ask your colleagues, ask [00:59:00] your neighboring units and get involved in 2020.
That brings us to the close of the episode. I can't thank you enough all of my guests for their time and insights, I've really enjoyed making this episode and it's been a privilege to have them involved.
I'm looking forward to a future podcast and ongoing conversation in 2021. I think now more than ever, it's really vital for us to maintain a dialogue. And if there's anything that you'd like us to discuss anything you'd like to invite us to cover, please get in touch by our website, or tweet us at BoneJoint360.
Whether you celebrate Christmas or not I hope you all get a much needed break over the next couple of weeks. And I look forward to our next episode in January with a bumper journal club episode focused on trauma in the context of the annual OTS meeting. So from everyone it's Bone and Joint 360, stay safe unwell and see you in the new year.