As the number of COVID patients across Scotland starts to rise significantly several areas of common concern within trauma and orthopaedics are emerging. Most pertain to maximising the safety of staff and patients in the operating theatre. There is also anxiety about the level of trauma service that can be maintained as this situation progresses.

The concern about the operating environment has been elevated in recent days following the publication of the surgical colleges’ intercollegiate guidelines for surgery during COVID (March 25^th). It is possible to interpret the guidelines as saying that all patients undergoing surgery should be tested for COVID and where possible surgery delayed until the result known. Where the surgery could not wait the patient should be treated as presumed COVID positive and full protective equipment used. This position presents practical problems for most sites just now as testing capacity and PPE is not in sufficient supply to meet these recommendations. The collegiate advice is also not consistent with Health Protection Scotland (HPS) or Public Health England (PHE) advice which recommends using full PPE only where COVID is suspected. 

Emerging evidence of potentially high levels of asymptomatic carriers of COVID may make the intercollegiate advice sound sensible but the current intercollegiate statement does not represent a policy change from HPS or PHE. The colleges are now working with these bodies and the CMOs to clarify the position but current advice remains to follow the HPS recommendations on PPE precautions.

The Intercollegiate statement also recommended not using laminar flow. Clarification was sought last night from the BOA which it should be noted did not endorse the intercollegiate statement. The BOA position remains that laminar flow should be used for all patients where available. 

We are in a time when numerous groups are hurriedly producing guidance with the best intentions. Where contradictions appear anxiety and scepticism is inevitable. I thought it might be helpful to see an excerpt from a statement by the Infection Prevention Society issued yesterday:

“The Infection Prevention Society are experts in preventing the transmission of infection in healthcare environments. We fully support and endorse the guidance on the use of personal protective equipment (PPE) for the management of COVID-19 from the joint UK Public Health bodies” “ We are therefore calling on clinical colleagues and specialist societies, whose expertise is not infection prevention, to refrain from creating confusion, anxiety and alarm by contradicting the advice from experts in this field.”

It is hoped and expected that we will soon be in a position where patients and staff can be rapidly and reliably tested for COVID and correct precautions taken. In the meantime we must rely on the best evidence we have and the use of sensible measures to protect our teams while still delivering the service our patients need. 

The Scottish T&O leads have been sharing a great deal of advice and common sense via their Whatsapp group and the following may be helpful:

• Avoid being in theatre during intubation or extubation (this is the time of highest risk) 
• Encourage use of regional anaesthesia in place of GA whenever possible
• Use power tools sparingly and on the lowest revs possible to reduce aerosol spread
• Use smoke extraction with diathermy if possible
• Use laminar flow 
• Surgery should be performed by the most experienced surgeon available
• Keep theatre staff and traffic to an absolute minimum for all cases

The BOA’s recent BOAST guidelines for COVID are important and useful and contain much of the advice above.

As pressures increase we will be facing redeployment of staff and loss of operating capacity. The BOA and SCOT fully support the position that we must protect a viable trauma service to provide life-saving surgery and avoid life changing morbidity wherever possible. That includes continuing to fix hip fractures if at all possible as we know the consequences of not doing so for most. If services feel that they are in a position where this is threatened then please communicate that via the clinical lead or director to SCOT so that we can understand the scale of the problem nationwide and raise the issues with the Scottish Government and BOA. By the same token, T&O will not shirk contributing to the general effort where our skills can be useful and redeployment not detrimental to the trauma service. 

The Scottish T&O community continues to rise to the huge challenges we face. With solid mutual support and good communication between us we stand the best chance of continuing to deliver the best service we can to our patients. 

Al Murray
Chairman, on behalf of SCOT

SCOT have recently updated the “Resources” section of the website. There is a new section on COViD planning where documents are shared for the use of clinical teams having to urgently redesign services.

There is also a new ACRT section which will include shared resources such as example “Patient Information Leaflets” and other pathways.

As Scotland enters the next phase of the COVID-19 response the orthopaedic community has been active in playing its part. We are all now implementing plans to postpone our elective services for all but the most urgent cases and reorganising to ensure we can continue to provide a safe trauma service for the duration of the crisis. 

SCOT has formed communication groups to ensure effective communication between CDs and leads across the country. Through this there has already been very useful sharing of ideas and updates on local situations. The following is a summary of the picture for T&O at the moment:

• There are discussions about possible regionalisation for vital trauma surgery such as hip fractures but at present health boards need to plan for managing these patients within their own facilities. It is important for us in T&O to ensure that Boards appreciate the vital nature of preserving trauma surgery which provides quick and effective treatment and minimises in-patient stay. 
• Some centres are reporting difficulty having their T&O teams fitted for protective equipment. There has been an issue with central supply and some delays encountered. Any activity involving an intubated patient who is positive for coronavirus is considered high risk and orthopaedic surgical teams must be given sufficient priority for fitting and supply of protective equipment. The BMA has issued a statement offering support where problems are being encountered. SCOT would also like to hear about these issues.
• With the postponement of most elective care some teams are looking at providing a clinic service from previously unused sites remote from the main hospitals. For example, NHS Lanarkshire are tasking the ESP workforce to plan and deliver what they can to ensure that urgent referrals and returns can be seen. 
• Many T&O teams have been asked to plan and provide a minor injuries service to remove this burden from the Emergency Departments. This requires a fair amount of planning and will be a particularly useful area for us all to share information such as protocols for certain conditions or safe use of sedation. 
• Another useful development adopted by some centres has been planning rotas to cover in-patients and ambulatory trauma but also build in time for teams to work from home for a few days at a time to reduce fatigue and exposure to infection. 

This is a rapidly evolving situation to which orthopaedic services need to respond urgently. Sharing of concerns, problems and above all solutions to the challenges we face will be vital in supporting each other and tackling this unprecedented situation in the best way we can. 

Al Murray

Chairman, on behalf of SCOT

16/3/2020

The Winter SCOT Meeting will take place at Crieff Hydro Hotel on 31/1/2020 – 1/2/2020.

Sponsored by:

• Depuy Synthes
• Arthrex
• LinkUK
• Stryker
• Smith & Nephew
• Joint Solutions
• Ossur
• Biocomposites

A programme is available for download.

For enquiries about attendance, please contact Ivan Brenkel.

Please note the following upcoming dates:

Winter SCOT Meeting (Crieff Hydro Hotel) 31/1/20 to 1/2/20

STOTS Meeting (Dunblane Hydro Hotel) 27/8/20

Summer SCOT Meeting (Dunblane Hydro Hotel) 28/8/20

Further information will be posted as it becomes available.

Metal Resurfacing of Hips

There remains concerns in the press and scientific literature about metal on metal total hip joint replacement bearing surfaces.  Hip replacements/ hip resurfacing with metal-on-metal hip bearings became very popular in the late 1990’s and early 2000’s with implant companies, the popular press, patients and some surgeons being a driving force. In the late 2000’s, however, it became  apparent there was a much higher failure rate (5-6x that of standard hip replacements in some patient groups) with these bearing surfaces. There were also incidences of significant soft tissue damage being caused by metal wear debris, so called pseudo-tumours. NHSScotland is aware of these concerns and takes patient safety seriously.  There are currently no total hip joint replacements using metal on metal bearings being performed in NHSScotland.  Hip resurfacing procedures are not routinely offered in the majority of health boards in Scotland and there are only a small number of specialist centres performing the procedure under close follow up. However, there may be a limited place for metal resurfacings procedures.  The belief that it is easier to revise a hip resurfacing than a hip replacement is misplaced.

This note sets out NHSScotland  position with regard to hip resurfacing with metal bearings. 

Choice

Patients should have the option to consider a range of choices to improve their quality of life when they have significant pain or lack of mobility due to damage to a hip joint.

Cohort

The group of patients to whom a metal hip resurfacing procedure is a potential option tend to be male, young, with good bone quality and with large diameter hips

Consent

There must be additional informed and recorded consent agreed with the patient that currently a resurfacing procedure does involve the use of a metal bearing and that there may be a risk of early failure and soft tissue damage due to metallosis.  The patient must agree, and the surgeon must ensure that more intensive follow-up is in place than is routine following standard total hip replacement surgery so any development of metallosis will be found early and managed properly in line with current guidelines for metal hip bearings from the MHRA. This follow up may involve yearly review and x-rays together with blood tests to monitor metal levels that can become elevated.

Surgeon

The surgeon must have significant experience in hip resurfacing procedures, record specific consent for the procedure and ensure follow up according to MHRA guidance

https://www.gov.uk/drug-device-alerts/all-metal-on-metal-mom-hip-replacements-updated-advice-for-follow-up-of-patients

Device

The device chosen must be one with a minimum 10A Orthopaedic Data Evaluation Panel (ODEP) rating Bor be part of a registered research trial.

Patients and surgeons should ensure that the advice from the British Orthopaedic Association and British Hip Society is followed.

Mr Edward Dunstan
Consultant Orthopaedic Surgeon
Chair – Scottish Committee for Orthopaedics & Trauma