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right. Hello. Good morning, everyone. Um, so it's a great pleasure to invite our three speakers who are going to be delivering the oral prize presentations out of 100 and 79 abstracts. Djamila, um, James and Michael are the three guys who have been selected to do this. They have six minutes to present, um, and three about 3, 3.5 minutes per question excitingly a UK. I have decided that they're happy to give you these These these guys prizes as well. So we'll have a 1st, 2nd and 3rd prize, uh, for the work, and I'll sort out that cash stuff later. But I was hoping to have a big check for you, but unfortunately, don't have one of those. But without further Do you mean if I can ask you to come and present, please? Okay. Good morning, everybody. My name is Jamell. I'm 1/4 year medical student at the University of Leeds. And it's an absolute privilege to be presenting our work on an early transition to remote follow up for circular frame. Patient's looking, particularly the question our routine radiographs required. Routine radiographs are commonplace in the follow up of circular frame patient's. However, there's a few things we don't know. We don't know whether they make patient's happier, make our jobs any easier or make the treatment safer. However, we do know that our clinics often overrun and the patient's often have to wait really long for X rays. A previous audit within our department showed that greater than 95% of the radiographs taken during the follow up of circular frame Patient's had no effect on the clinical management, in particular during the mid phase of treatment. The NHS long term plan highlights the outpatient appointments are outpatient appointments are no longer the best way to deliver care and that they require fundamental redesign, integrating technology into our delivery of care and covid 19 legend rapid enforce change within our care model. So the traditional pathway utilizes an impatient X ray, which occurs during the post. Operatively and patient's come in routinely 246 weeks, um, throughout the course of their treatment to have X rays and face to face appointments. Um, during the new pathway, the patient's have an in pain X ray. This is used by a senior surgeon who estimates the earliest point of frame dynamism, ation and patient's don't have routine face to face appointments until the estimated point of frame dynamism ation. Rather, they They have routine telephone appointments, and they have an X ray at six weeks, which can be done either at our institution or within their local department. Um, so the new pathways explained to patient's. We tell them about our previous lot at work, and we tell them why we're doing it. Um, we also have some patients who are unsuitable for the, um, new pathway. So patient's who are too vulnerable or who we feel we don't seek help should they require. All the patient's are given the phone numbers and email addresses of our from specialist nurses. Should they have any concerns about their frames and these acts as the first point of contact. So the object of the study was really to assess the safety of it, um, and to assess the ability of it to reduce the number of face to face appointments and X rays. So our patient's were selected from our, um, really um were identified from our prospectively collected Limerick construction database and chart Review was undertaken. The results were compared to previous cohort of 78 Patient's and they were all. And complications were classified as problems, obstacles and then complications and reviewed by a senior surgeon. Um, so 26 patient's were eligible for inclusion. Um, so in phase two, we had, um, slightly more salvaging elective cases. These tend to be more complicated than the trauma cases. Um, and the patient's in phase two are younger. Um, so all cases the Chiefs union with the medium frame time of 22.1 weeks. Um, and we had into it'll during phase 232 clinic appointments, um, 40% of which were through the telephone remotely. And we have 316 x rays undertaken during this period of time. So in terms of the results, um, we can see that from phase one to phase two, there was a decrease in the number of face to face appointments, uh, in the number of clinic appointments going from medium of 6 to 4.5 per patient. Um, and we can see in its ability to reduce the number of face to face appointments, there is a decrease from a medium of six to a medium of three, Um, and we can see an ability to reduce the number of X rays per patient's Um, there was a statistically significant decrease going from medium of 25 to 10, and all of these were statistically significant when we analyze them. So in terms of adverse events, the majority were low morbidity problems that we expect with the tree of circular frame, patient's pinsight infections and broken wires. There were two obstacles. A persistent pinsight infection, which required incision and drainage. Um, and we had one distal fixation failure, which required return to clinic. There was one complication in a patient who opted for a premature removal of their circular frame. So, looking at the sort of X rays, we can see that this patient hasn't had any X rays for seven months. They haven't had routine face to face appointments, either. They've just had telephone appointments. We can see that at the time frame dynamism, a shinin removal. The fracture is united, the fracture hasn't lost position and the patient is ready to have their frame off. Um, so there's a multitude factors leading to the success of this within our service patient's are educated regarding common frame complications so they know what to look out for. Um, there's lots of pathways of contact, so they're given the email addresses of our frame specialist nurses and the frame specialist Nurses act as the first point of contact for any patient's concerned about their frames. So if we look at a moderately sized service, let's say a patient puts on 30 frames per year. We're able to see a potential decrease going from 90 a potential decrease of 90 appointments per surgeon per year. Looking at the ability to reduce the number of X rays, we can see that there's a decrease of 450 films. Um, if you put on 30 frames in a year, um, from our study, we you can see that there's no evidence of, um, increased um, complications. The majority of the events that happen that were adverse were the low morbidity problems that we commonly see pinsight infections and broken wires and the X rays were reviewed by a senior surgeon who felt that none of them had lost position during the course of treatment. So, um, outpatient appointments are overrun, and this is a pan specialty issue. Um, technology is the way forward. We really need to incorporate telephone appointments and video consultations from our study. We can see that there is potential to integrate this within our care delivery and that it does have the potential to decrease the number of face to face appointments and the number of X rays and further work is needed in a larger cohort to clarify this. And we also need to clarify the perspective of patient's. But there is a great deal of potential. So another X ray this patient hadn't had, um, routine face of disappointment nor X ray for five months. And we can see their frame was removed. Their factory was united and they were able to walk out of clinic. Very happy. So thank you very much, everybody. Fantastic. Thank you very much. I'll any questions for our speaker? Hi. Yes, genetic with those things up you were doing anywhere Fight influencing this. You actually change the information or indecent. So what? I actually changed. Yeah. So in terms of, um, so we already had the frame specialist nurses. Um, and we already, um, sort of gave patients' information once they've had their circular frames for so on. But when we sort of transition them to a remote follow up, they were given the contact details of our frame specialist nurses. And, um, in terms of sort of, you know, when you're sat in a clinic room with your patient, you sort of give them a little bit more information when you're about to transition them onto your remote follow up model. Um, So, um, I'd have to check with the with the surgeon, but I don't think we give them any extra sort of like leaflets or anything like that. But they were certainly sort of talked to and counseled more about the remote follow up before starting it. Um, so not all of the patient's were sort of a case of we can't see you. So not all of the patient's occurred during COVID. Um, we still continue to use this, Um, but we said that we've done a previous audit in our department. We find that the majority of the time patients come in to have an X ray to be told that their leg looks perfectly fine and that they could come home and come back again in four weeks. Uh, so we explain that to the patient's, and we tell them that we're going to put them on to sort of a remote pathway whereby we have regular telephone appointments. But they don't have regular X rays. They don't have regular face to face appointments. And if they're concerned at all about their frame, these are the contact details of our frame specialist nurses to come and discuss. That's excellent, Thank you very much. So can I buy the next speaker to come on up? Just remind me if anyone has any questions. You need this, Mike. Thank you. So thank you very much, everyone and particularly thank you to bow to forgive me the chance to present this. My name's James Arch, and I'm one of the orthopedic registrar stand in Birmingham. I'm talking about the boom audit. So the British Orthopedic Oncology Management Audit. Now this is a prospective multi center national collaborative audit collecting data over three months for all patients with metastatic bone disease. We collected loads of data points, so things like whether the center had a metastatic bone disease lead demographics of patient's, the investigations, referrals, management, follow up, lots of information about them. We managed to do incredibly well in in a three month period. So we managed to get 100 and 11 sites to register and 84 of those submitted data over that three month period. Now around about 51 to 61% of them actually had a metastatic bone disease lead. Who might have helped push the that we would do this, but a lot of them didn't. More than anything else, I'd like to say a massive thank you to the 273 collaborators across the centers who managed to collect data for us. And for some reason, I'm sorry it's cut some of them off and move them around. But without all of these collaborators, without this trainee led collaborative, we wouldn't have been able to collect so much data in such a short space of time. And it really shows the power of trainee led collaborative. So we managed to collect data on 846 non Spinal Patient's. We actually collected data on over 1000 patient's but have excluded the spinal patient's because their pathways are slightly different from metastatic disease. Around about 50 50 split male to female and, as you would expect, age shift towards towards older age with a median age of 71. And more than 90% of patient's being greater than 50 years of age got referrals from all over the place as again as you would expect, probably the biggest source being emergency departments, but also other departments within the hospital, like oncology, um, as well as G P services. And again, the lesions that we saw the all the ones that we expect to see so most commonly with the long bone lesions but also multiple sites. The most common primaries with prostate, breast and lung around about 74% of patient's had a known primary at the time of their presentation to an orthopedic service. And the reason I've mentioned that it's really important to note that that improved to 93% once we started doing our primary investigation. So our usual CT thorax, abdo pelvis, our our standard investigations, and I'll come onto why that's so important as we move through so imaging, probably the cornerstone of what we do in orthopedics. But actually our completion rate of imaging for patient's with metastatic bone disease is pretty poor. So we saw that overall, our rates weren't great for anyone. Modality that none of them had hit 100%. When you completely included all three modalities, only 26% had complete imaging again. There might be reasons for that. These might include patient's who are just absolutely not fit for any operation or intervention. But it's still quite worryingly low then, when we look at, uh, input from the oncology team and from tertiary services. So oncology input was actually pretty low again. So the number of patients who actually had an oncology input with a prognosis which will help to guide us whether we're going to offer this patient, for example, a surgical intervention it was only 26%. And again when we look at the number of patients who referred onto a tertiary service, even if that's just for advice is, uh, more than 50% of them. I'm sorry, 50% of them about we're not referred on. So when we look at the solitary metastases, so these the ones were probably the most worried about because these are patients who potentially either got another primary, so this could be a primary lesion, or this could be a lesion that is amenable to primary resection and therefore curative resection. And actually, when we looked at the data again, the treatment of the this particular group is pretty poor. And one of the standout findings is that patient's who went to a site that had a metastatic bone disease lead at the hospital were significantly more likely to refer. The patient's on to a tertiary unit and therefore hopefully get specialist input and hopefully the best outcome for that patient and those who are surgically managed. So these are the patient's who have decided or who have gone on to have surgery. These are ones you'd expect to have the the best quality of investigations. And again, the rate of imaging staging oncology input were again really, really low and very, very worrying because these patient's that were deciding on on their management, and we don't have all of the information available to us, and then when we start to look at how we manage these patient's with surgery, this quite a big difference that you can see in the rates of intramedullary nailing an endo prosthetic replacement between those treated in a secondary, all those treated in the tertiary unit. Now again, I fully understand that that there is a big selection bias. Their patient's who've ended up being discussed with the unit or going to a tertiary unit might be the ones who are most suitable for an end of prosthetic replacement. But that's still quite a big difference in there in the rate. So it's, I think it's something that's worthwhile, considering that may be all those patients' treated in a secondary unit. How many of those, if they've been discussed with the tertiary unit, would have ended up going on to having different treatment? So in conclusion, we've present or I'm trying to present a huge amount of data I'm trying to cram down into six minutes. But we had 846 patient's, which is the biggest group of metastatic bone disease patient's, I think, probably certainly ever collected in the UK and probably ever worldwide. Um, the results show that we've got huge room for improvement, so only 26% have their complete imaging. Only 43% are having oncology. Input with prognosis and particularly worrying is those who go on to surgery. Only 30% of them have got complete staging and imaging performed. And in the case of solitary lesion, we're seeing significant differences in the Treasury referral patterns in those centers that have a metastatic bone disease and lead and those that don't. So hopefully this will drive some changes. Fingers crossed. It will be published soon. Trying desperately and I've been working very hard, and it's I think it's almost there. Uh, there's now boast that's come out off the back of this as well, to try and improve services and hopefully will lead to improvements within departments. Thank you very much. Any questions? Thank you very much. Um, I have a question, if I may, um so obviously, at the after presenting this, this is actually not to boast guideline, which shows that this is the progression of work. How are you going to Are you planning on re auditing this? Are you doing another national project to try and see how things are? When are you going to be doing that? Yeah, so that is absolutely The aim is we're really proud of how well a trainee collaborative has managed collect so much data. in such a short space of time. And we're hoping that in a couple of years time, probably to give it time for those boats to filter through that we can then re audit and again try and recruit trainees in to try and show whether there has been a difference or there's been any change. Um, yeah, only time will tell. Hopefully it will improve. Okay. Any other questions? Right. Hi, James. Messy again. Great project. Have you got any data on the geographical spread of where, where departments have leads for metabolic bone disease and not? Yes, we do. So there isn't any particular split in terms of which departments or which areas are most likely to have a metastatic bone disease lead, and it doesn't seem to make any difference in terms of the referral patterns to centers. The only thing we found in the main paper is that if you are older and further away from a center, you are less likely to be referred in. That's the only statistical finding when we looked at the distance from tertiary centers and whether you have an M B D lead and things like that's the only one we found there's one just behind, so I will well done. Good presentation. Um, forgive me if I'm wrong, but in order to full imaging X ray CT and MRI scan for multiple and single metastases. Are we there for advocating? We should be MRI ing cancer patient's that have multiple metastases. And should we be MRI ing all of there? Mets? Yes. So that that's a very fair point. So that's why I say particularly the ones that were managing surgically are the ones where I was most worried about them having full imaging because you're right. If somebody's got multiple mets, then if they're in need a whole body MRI and I think the official The Boost Guide, British Orthopedic Oncology Society Guidance says MRI of appropri area. So, for example, if you're going to nail the femur or put an intramedullary now down the femur, then you should have an MRI of that. And that's what we included as our priority in terms of imaging within three months. So if they were going to have a nail, they should have had an MRI of the femur is what we use as our rather than MRI of any lesion. They might have anywhere else. Yes. Yeah. Thank you. Did you collect the data about chemo and radiotherapy? And also, did you collect any clinical throw t score? Because most of the patient is quite elderly. Yeah, absolutely. So, no, we didn't collect anything on chemo and radiotherapy. We tried to get the oncology. So the equivalent oncology team to be involved in terms of as part of the national or project and they couldn't get anybody together, They couldn't do it in the same way that orthopedics can, which is? Yeah, go orthopedics. But unfortunately, couldn't get them. And you write again, clinical frailty. Something that's pretty important again. We didn't. We chose not to collect it because most centers didn't have that data available or couldn't tell us accurately what their clinical frailty was. So no, we don't have it. We're basing. It based a lot of it off what they had as their management as to how good they were and their prognosis if we got it from oncology. Thank you. Thank you very much. Thanks very much. If I can find my last weekend Michael to give us talk. About six minutes. Mhm. Hi. I'm Michael Pollinger. I'm an s t four in the east of England. Dina re, uh, I'm going to show you some evidence based thresholds for trauma competence, uh, each of the waypoint stages of training. So the new curriculum and recent discussions that b. O. A. Have focused on producing competent Day one consultants with a move away from a focus on just numbers, uh, heavier emphasis on working to level four p B. A s at the completion of training, but are expected. Development trajectory is not clear, and it's important, but difficult to objectively identify trainees that are falling behind. So to look at this, we sent a survey to 32 trainers and 73 trainees in ordinary. We use surveymonkey and the modified Dillman method. Oh, so that's kinda bit funny. But for the trainers, we had, uh, 22 responses and 53 trainees responded for that graph is supposed to show a variety of, uh, levels of training. They were asked their expectation of these different operations S t four s, t six and ST eight. So, uh, in essence, this is a tension band. Weir of electron Fraction weber. See ankle fracture, fixation supracondylar fracture fixation, uh, distal radius? Or if and fixation with K wires, radial shaft fracture, fixation, hip hemiarthroplasty, DHS and tibial. Now, okay, we use the standard PBA levels, so I'm going to present the results. Hopefully, on these sort of lava lamp graphs up the Y axis is PBA levels. And on the X axis is the different operations. So the area of the circle is corresponds to the number of responses in this example. Uh, one response for one B for attention band Weir, but 10 responses for four A for attention band Weir, uh, put the trainees at the top and the trainers down the bottom to show their results separately. So s t eight, Maybe. As you'd expect. You can see for four, be the red circles. Training expectations for the majority of procedures are four b a s t eight. I don't think that's a surprise for the trainers. It's similar, but you could argue there's a few more orange blobs on there showing slightly lower expectations from the trainers. Yeah, uh, ST six. It starts to spread out a bit, and you could argue that it looks a little bit like a normal distribution for some of these responses. Um, but the majority is still expecting level four, which are the top red and dark blue circles. Mhm trainers. It was. Excuse me. Trainers also have similar expectations, but you can see supracondylar fracture this one on the right, um is starting to look a little bit different to the others. And again at S t four. That spreads even more. So you get similar sized circles of lots of different colors. And again, you could probably argue that supracondylar looks a bit different in its geometry for both trainees and trainers. So this is quite interesting, right? That's a lot of data. And there's 216 colored blobs. I know because I counted them this morning. Um, how do we actually make that useful? And why am I bothering to tell you about it? Well, we've proven probably as expected, that is majority agreement at ST eight. And and there's a variability of expectations at S t four and ST six. So I spent some, uh, long and expensive time with some statisticians, and we haven't been able to show that there's a difference between the trainees and the trainers there's no statistically significant difference between the trainees and the trainers. So we analyzed it all as one single data set and found groups with shared lower quarters of expectations. And we proposed these thresholds for our expectations for benchmarks for trainees at each of the waypoint stages. So I show those to you now s t a. Obviously the groups are pretty similar, but s t 63 groups become apparent what we call basic trauma Group one. So hemiarthroplasty DHS came wherever distal radius and ankle. Or if group to intermediate trauma. So tibial now, electron tension band, radial shaft, or if and Distal Radius or if and then supracondylar like you can see from those graphs sitting separate from the others. Uh, and so we've got the expectations here in this chart so you can see the group one at ST for the expectation is three a for these procedures at ST 64 a. And then we'll see S t eight then for intermediate trauma, the expectations are slightly lower, So the lower quartile of trainees should be getting to be for these procedures. S t 43 bst six and of all four at ST eight, and then the expectations for supracondylar lower, like you can see from the graphs. So for the first time, these are evidence based and easily accessible thresholds for trainees as they progress through training. And we suggest that these are useful for trainees, trainers, clinical and educational supervisors and a r C. P. So I've shown variability and responses to our survey ST six and S T four way points. No, statistically significant difference between the trainers and the trainees. And we've provided the practical table for discussion about expectations for where people should be at each of the waypoint stages. Uh, the references are for my pictures. Okay. Thanks very much for listening. Happy to take any questions or stick them in the metal box. Great. Thank you very much. Perfect. Sure yet Mhm. Thank you very much. That was a really interesting presentation. I was just wondering. Has your dean we now taken this on as a standards for a r C. P across the board for your own trainees? So, in a recent communication from our CPD who sent out the table saying these what we expect from you at S t four s t six and s t eight. So I guess, Yes, but not so it's not a if you're not this level, you're out. But more as a guidance for this is the the lower threshold for what you'd expect. She said, Yeah, yeah, yeah. Um, Thank you, Michel. Those are interesting presentation. Did you was the very beauty of seniority, Or how long the consults, how many years the consultant have been consultants for in terms of the trainer expectations? Yes. So I'm sorry. That graph didn't quite project. So, uh, consultants were They went up to 10 years for consultants, and they were or had been educational supervisors. So we looked at all the educational supervisors in the Dean ary. We didn't specifically ask about the clinical supervisors. There is a spread from we had to be in blocks from not to 55 to 10 and over 10 years. And there was a reasonable spread in the consultants. But there's only 30 So, yeah, there was a mix ask question, Mark. Thank you very much. That's really interesting. Um, in some Dean Aries around the country, the structure of the rotations over the six years is limiting in that sometimes if you do a rotation early on where you may only get that procedure in that rotation, you feel a pressure to put down your level fours, maybe even s t. Four. So how do you demonstrate progression during your training when you may only get your superconductors in your P's rotation at ST four? Uh, I think that's a very good question, too. If you're not doing more operations, it's hard to demonstrate any progression at all. And I think that is one of the focuses, certainly that we've been told that the aim is to progress. It doesn't really matter where you started as long as you're getting better. But if you're only doing that operation in one block, you have no chance. But maybe you need to show your progression in that block to getting your I don't know, to be in the first two months and then progressing to get your level for at the end of your six months to still be able to show progression, but just in the block. But this wouldn't work for those particular procedures, and that may be, I think it's interesting that Supracondylar fracture fits as such an outlier compared to the others. Yeah. Fantastic. Thank you very much, Michel. Thanks. So, um, that concludes this That part of the session. So we've actually been doing remote, uh, marking for all your presentations this morning. So we've been marked on timing clarity, and you're answering your questions. So we've got I got some certificates for you. So in third place is Michael. Thank you very much. A photo to be taken for the Hi. Okay, Thank you much. Second price goes to Djamila. Thanks so much. And our winner is James. Yeah, thank you very much. Yeah.