From Exams to Excellence: Meet Mr Dan Morell, the Hand Surgeon The hand surgery training pathway is a long journey. There are lots of exams and time locked away in a room away from family and friends with your head in a book. There are lots of sacrifices, missed birthdays, weddings, and festive seasons (you get the idea!). Surgical subspecialty training in orthopaedics: Towards the end of surgical subspecialty training in orthopaedics, most surgeons will take an exam which signifies their competency in that speciality. For Orthopaedic surgeons, that is the FRCS (Fellowship of the Royal College of Surgeons) exam. It consists of a written component followed by a 2-day clinical and viva exam that is conducted by trained examiners made up of senior Orthopaedic surgeons from across the country. FRCS Exam: Everything up to that point is focused on the exam and it becomes like a heavy burden across your shoulders, weighing down every decision you make. The relief of success is one of elation and freedom, as for most surgeons, this will mark the very end of a long line of academic exams. Unfortunately, for a hand surgeon, this isn’t the case. One more exam looms the British Diploma of Hand surgery. British Diploma of Hand Surgery: Hand surgery is a combination of both plastic and orthopaedic surgery and the Diploma is designed to cover the entire breadth of the hand surgery curriculum. It includes approx. 1200 educational hours; 32 tutorials; a literature review – amongst other coursework; a written exam and this is all followed by a 2-day viva and clinical exam. Challenges of studying while working: I began studying for the Diploma during my fellowship in 2017/18 at the Pulvertaft Hand Centre in Derby. Studying whilst working is difficult, especially when the commute is long, and although I achieved the majority of the required tutorials, I soon realized that I wasn’t going to be able to complete the Diploma within the year. In October 2018, I succeeded in getting a job as a consultant at Doncaster and Bassetlaw Teaching Hospitals. The task of managing theatre lists, clinics and the endless pile of admin became my main focus. COVID-19 Pandemic: In late 2019, I refocused on the exam, but the COVID pandemic disrupted everything, making exams seem insignificant compared to what the world and the NHS faced. Decision-making: Fast-forward 2 years and I’d now become an established hand surgeon. I had a choice to make… The driving force for many to work toward the Diploma is the subsequent enrichment of the CV. With this additional feather in your cap, work opportunities become more accessible. Having been a consultant in post for 4 years altered the landscape for me. I weighed up my options and discussed them with colleagues, family and friends; they asked: “If you pass, will you earn more money?”…. “No.” So why are you going to put yourself through it then?” I also had to consider the risk of failure, in front of peers whom I admire and respect. That would surely only do my reputation damage. On the flip side, I felt like there was something missing: a small niggling feeling called regret. I didn’t like this feeling and I wanted to be assured that when I see patients, I can confidently advise them that I have studied the entire breadth of what is known about the surgery of the hand. Although it was a gamble, I decided to go for it. The Exam Experience: Six months of studying later, coursework and more weekends locked away from my wife and daughter, I’m in Birmingham ready to sit the clinical. Waiting for that bell to ring to go into that room, where destiny awaits is a bit like sitting at the edge of an aeroplane preparing to leap out and skydive: heart racing at 100 miles per hour. Why am I so nervous? Because this is important to me. I want to succeed. The results arrive the following day with a phone call from the exam supervisor. It’s good news. Suddenly all that stress is worth it. My family share in my joy; it’s not just my success but our success as they have been the ones to carry me through it.

What is your Rotator Cuff and why is it a Painful Topic? Shoulder pain is very common and rotator cuff problems are a frequent source of that pain.  We often take our shoulder movements for granted but issues in the shoulder can be very debilitating. They often cause us problems with simple daily activities such as washing, dressing, brushing our hair and even getting a good night’s sleep.  If this sounds familiar, then please read on to find out how you can get the right rotator cuff support. What is the rotator cuff? Four muscles, known as the rotator cuff, attach to the shoulder blade and surround the ball and socket joint. Individually they rotate the shoulder in different positions but together as a team, their main job is to hold the ball in the socket.  This provides stability and allows the bigger muscles to move the arm into various positions.  Each of the muscles forms a tendon which attaches along the edge of the ball (head of the humerus bone) forming a single cuff of a tendon (hence the name rotator cuff). What causes rotator cuff pain? Disorders of the rotator cuff range from mild inflammation to a full-thickness tear of one or more of the tendons. The Most Common Cause of Rotator Cuff Tears: Not just an acute injury, but also due to chronic wear and tear from repetitive actions in certain sports and occupations such as tennis, swimming, golf, or heavy lifting jobs like plumbing, electrical work, and carpentry. What are the symptoms? Pain Experience pain radiating from your shoulder to your upper arm during overhead activities or when reaching your hand to your back? This discomfort can also cause a general ache even at rest, and may even disrupt your sleep, especially if you roll onto the affected side Weakness This is usually due to a tear in the tendon but can also be secondary to pain caused by an inflamed tendon.  With very large tears it may be very difficult to lift the arm at all; almost as if it is paralysed.  This is called pseudoparalysis (false paralysis). Clicking and cracking Dysfunction of the rotator cuff tendons can lead to poor control of the ball in the socket of the shoulder which often causes clicking, popping or cracking when you move the shoulder.  This can sometimes be painful. What should you do if you think you have an injury? If you think you may have a rotator cuff problem, you should speak to your GP as you will require further investigations to diagnose the problem.  Following this, it is likely you will be referred to see a specialist shoulder surgeon to discuss the treatment options.  The common shoulder investigations are: Radiographs (X-rays) – This will show the bones of the shoulder and, although you can’t see the soft tissues clearly on x-ray, sometimes changes in the bone where the tendons attach can give an indication of problems with the tendons themselves.  Any arthritis in the shoulder will also be detected with this investigation. Ultrasound – This is a simple, non-invasive investigation, which is very good at looking at the rotator cuff tendons.  It is very reliable at detecting inflammation, thickening and tears of the rotator cuff.  Ultrasound can also be used to accurately give injections into the shoulder if indicated. Magnetic Resonance Imaging (MRI) – This is a very reliable investigation which gives a clear view of the tissues in the shoulder including bones, cartilage, ligaments and tendons. The MRI not only identifies rotator cuff tears and inflammation but also determines the quality and level of retraction of the tendons. This helps determine which tears are repairable. Identify Shoulder Joint Arthritis with MRI Scans What treatments are available for rotator cuff injuries? Treatment depends on the severity of the injury. Treat rotator cuff tendinosis with an injection to reduce inflammation and follow up with physiotherapy to strengthen the rotator cuff muscles and prevent the recurrence of inflammation. In the case of a rotator cuff tendon tear, surgical intervention is more likely.  However, not all patients need surgery.  Up to 50% of people over the age of 60 will have chronic tears and no symptoms at all.  Unfortunately, these tears never heal and if symptoms are affecting daily life and sleep then treatment will often be required.  If the tear is small, strengthening the remaining tendons with physio may improve symptoms, but often the weakness never fully improves.  A steroid injection may help improve the associated inflammation but will not repair the tear.  With bigger tears, surgery is often indicated.  This involves keyhole surgery to repair the tendon back to the bone using small anchors. What are the consequences if I don’t get treatment for my rotator cuff problem? Large, retracted rotator cuff tears can be difficult to repair.  If the tendon has been torn for a long period of time (many months or years) and the tendon quality is poor, the surgeon may be unable to repair it.  The rotator cuff tendons play an important role in stabilising the ball within the socket of the shoulder joint.  Tears over a long period of time can, therefore, lead to arthritis in the shoulder.  In both scenarios, keyhole surgery is unlikely to successfully improve symptoms.  In these cases, a shoulder replacement may be the best option to get rid of patients’ pain and improve function. If you are experiencing symptoms of a rotator cuff injury it is important you seek medical advice soon, especially if you have had an acute injury to prevent less severe injuries from getting worse. Get Rotator Cuff Support. Book Today #shouldersupport #rotatorcuffsupport #shoulderpain #rotatorcuffpain #shouldertreatment #shoulderinjury #arthritis

There are several causes for a painful ankle. Keep reading to learn more about the cause of your symptoms and how you can get treatment for ankle arthritis in Doncaster. What can cause a painful ankle? Pain around the ankle is generated from the soft tissues around the ankle including the tendons, nerves and ligaments or from within the joint itself. Most commonly, pain is caused following an injury to any of the above structures. The other causes include arthritis, gout, rheumatoid arthritis, injury to the ankle, stress fractures, a sprained ankle, Achilles tendonitis and infections. When does your ankle pain signify ankle arthritis? It is difficult to be certain of ankle arthritis. If you have constant pain in your ankle and you are noticing stiffness in the joint limiting the movements, please consult your doctor who will examine you and perform weight-bearing x-rays of your ankle. You may need a referral to an orthopaedic foot and ankle specialist. You may also need a few more investigations depending on the stage and type of arthritis. Commonly, ankle arthritis is injury related. Other causes of ankle arthritis include reactive, inflammatory, gout, infective and rheumatoid arthritis among a few others. You may need some routine blood tests and scans to determine the root cause of your symptoms. How can you manage ankle arthritis? Support your ankle with a brace that you can get from the local chemist or online stores. Modify your lifestyle – include physical activities, take routine anti-inflammatory medications (advice from your doctor), and do some physiotherapy. If these measures fail to relieve your symptoms, you may need to seek specialist advice. Seeking Treatment for ankle arthritis – what are my other options for managing it? The management will depend on how bad your arthritis is. In very early stages, a single injection in the joint will suffice, followed by continued non-operative treatment. If the arthritis is associated with some mechanical symptoms, a joint cleaning procedure carried out through a keyhole (arthroscopic) surgery may be useful. This is called ankle debridement. It is a day case procedure involving a couple of very tiny cuts in the front of the ankle and assessing the inside of the joint through a telescope to clear off the painful inflamed tissues from within the joint. If there are associated deformities of the bones or joints, you may be eligible for a re-alignment procedure which will bring your ankle and heel to a straight position. If your ankle arthritis has progressed to bone-on-bone (end-stage), you will be offered a fusion (ankle arthrodesis) or an ankle replacement. Which is better for you: a fusion or a replacement? An ankle fusion is a preferred option for someone who is less than 50 years of age, has a physically demanding job, and has an active lifestyle, with good joints in the rest of the foot. Ankle replacement, on the other hand, is suitable for someone with a sedentary lifestyle and with good muscle balance around the ankle. If other joints in your foot are also affected by arthritis, an ankle replacement is advantageous. However, in the case of severe deformity and instability in the ankle joint along with high BMI, an ankle replacement is not preferred. Your specialist will discuss this in detail. Get in touch with us to find out how we can help you today: Get In Touch

Complications following any Orthopaedic surgery can occur. Blood clots, more commonly known as deep vein thrombosis (DVT) can easily form in the limbs, especially the legs, following any surgery that results in reduced activity for a period of days. Keep reading to find out how to prevent blood clots after surgery and whether you might be at an increased risk. What can happen if you get a blood clot after surgery? It is fair to say that we as clinicians have become quite obsessed with trying to prevent postoperative DVT as it can have significant consequences. Not only can the clot travel to the lungs, with possible fatal consequences, but also may cause long-term damage to the veins, reducing circulation and increasing long-term swelling and pain. This situation is known as post-thrombotic syndrome. How can I prevent a blood clot after surgery? Now, whilst this information might be a bit scary, understanding the risk factors that can lead to DVT will help you to reduce the risk. We as clinicians consider a number of risk factors as part of the pre-operative workup. We complete specific forms which are attached to the medical notes documenting any of the risks identified. Unfortunately, whilst we can identify risks and provide appropriate prophylactic measures, we do not have a definitive formula for prevention.  What we mean by that is that we can only reduce the risk and not eliminate it completely. How do I know if I’m more at risk? Factors we consider include: 1. Age – patients over 60 are at higher risk 2. Weight – obesity increases risk, especially BMI greater than 30 3. Personal or family history – patient history or first-degree relative history of clots 4. HRT or contraceptive medication – oestrogen-containing medication increases risk 5. Varicose or pre-existing damaged veins 6. Immobility post-op – patients who are non-weight bearing or immobilised in a cast have an increased risk 7. Duration of surgery – operations taking longer than 90mins have a higher risk 8. Type of surgery – hip and knee replacement carries a high risk 9. Smoking – damages circulation and can increase risk How can I prevent blood clots after surgery? Some of these factors such as weight and smoking can be improved by yourself. Keeping yourself fit and choosing a healthy lifestyle will reduce risk significantly should you ever need an operation. Temporarily stopping HRT/contraceptive medication 4 weeks before surgery reduces risk. Keeping well-hydrated post-op, by drinking 2 litres of water daily, will also reduce risk. If your surgeon considers your risk to be low, then simple exercises to move the affected limb along with good hydration will be advised. In high-risk cases, whilst in hospital, mechanical pumps to squeeze the calf, compression stockings and injections of blood thinners into your tummy may be prescribed. You may go home with injections to self-administer or a blood thinning tablet to take daily for a prescribed period of time. After the first 2 weeks, aspirin may be used for a period of 6-8 weeks to further reduce risk. If you are particularly worried about blood clots, do speak to your surgeon who will discuss this in more detail. Get more tips on how to recover from surgery and learn how we can help you treat a range of conditions in Doncaster below: Recovering From Surgery Treat Orthopaedic Conditions

Enhanced Recovery from Surgery – The 3 Phases A common question patients ask is: how can I have the best recovery from surgery? Of course, it depends on the type of surgery, but you should consider the recovery in 3 phases. Understanding these phases will help you manage your expectations for the most enhanced recovery from surgery. What is orthopaedic surgery? Orthopaedic surgery is basically a controlled injury to soft tissues and bones. It involves cutting the skin and essentially breaking the bone. The only difference from a normal injury is the mechanism of how it is done. Phase 1. Injury: This phase involves an initial period of wound healing. At this point, the swelling and reaction to injury will be at its highest. This is why your surgeon will ask you to rest and minimise normal activities to essential things like “going to the toilet” or “going up to bed”. You may be asked to elevate your limb and use ICE to minimise swelling. This phase usually lasts around 2 weeks, at which time any stitches or clips holding the wound together will be removed. Phase 2. Acceptance: This is the period of initial recovery as you start going back to more normal activity and work. This phase really does depend on the procedure undertaken. In general, it will be another 4 weeks after the injury phase is complete. The patient will be allowed to mobilise more, and may begin some physiotherapy but, in essence, will need to “accept” the time specified. Phase 3. Frustration: This may well be quite a difficult phase. Usually around 6-8 weeks post-op, your surgeon will advise you to return back to normal activity. Your own body, however, will dictate what you can do by swelling and causing pain if you overdo things. In this phase, you need to listen to your body and continue to rest, ICE and elevate as needed. You will likely become “frustrated” with progress, as it will feel like a long time. Remember, however, the less you do in the initial “injury phase”, the quicker you will get through the “frustration phase”. Normally things really start to improve at around 10 weeks post-op. Enhanced Recovery from Surgery – where to learn more In essence, listen to the advice given, listen to your body and have a quick and safe recovery. Make sure to check out our blog for more health tips and get treatment for a range of conditions below: Latest News Treat Orthopaedic Conditions

Is the NHS being affected by the private healthcare system? So you attend a private hospital as an NHS patient. It may leave you confused? Is the NHS being privatised? will I be asked for any payment? How is it that I can be seen in a private hospital if I’m not private? How do the NHS and the private healthcare system work alongside each other? How the NHS & private healthcare system work together The reality is, NHS & Private healthcare going hand in hand is not a new thing. In fact, the independent sector has been offering NHS care for at least 20 years. Initially, this was under “spot purchase” where NHS hospitals would outsource work to reduce waiting times. Latterly private hospitals have become primary providers of care through ‘choose and book’. This is where your GP practice can book directly for any qualified provider service either traditional NHS or independent hospital. Is the treatment quality worth the cost? So does this cost more? The answer is no. Each patient treatment episode carries a standard NHS tariff which is paid to both NHS and private hospitals when they do the work. You may find that treatment times vary, with private hospitals seeing and treating patients quicker, however, there are measures in place to prevent patients treated at NHS hospitals from being disadvantaged. The main advantage to patients is that you will always see the chosen consultant in the private sector, whereas in the NHS you may see a member of the consultants’ team Remember, on the whole, the patient has the right to choose (within reason and area) who they wish to see, so consider that when you visit your GP and discuss your preferences with them. Looking for private orthopaedic treatment? Our specialist consultants can treat a range of conditions – from foot and ankle injuries to groin pain. Learn more and get in touch below: Conditions We Treat Contact Us

We are delighted to say that one of the small businesses we use for our corporate gifts is about to get national exposure! Jen Wright from The Cocktail Pickers Club is appearing in the new BBC1 Gordon Ramsay series Gordon Ramsay’s Future Food Stars. Jen’s cocktails  are marketed as Taking the mess out of making cocktails with fresh, fruity and naturally delicious ingredients. Just simply give them a quick shake and serve ice cold! We’re sure she’ll be amazing! To find out more about Jen, visit her LinkedIn profile here #localbusiness

Often when it comes to discussing surgical procedures, some patients will say, “I don’t want to know the details just get on with it”. Problem is, in modern day medicine, the law on consent has shifted from “Doctor knows best” to “shared decision and responsibility”. This is certainly a good thing as it means that the the patient receives a much more detailed explanation of the planned procedure and risks associated with the procedure. Written advice sheets are now more or less mandatory, some with diagrams demonstrating the surgery. Back in the day we used the Bolam test to measure consent to treatment. This essentially meant the the procedure carried out was in line with what a “body of medical opinion” would do. In other words, do your medical mates accept it was the  right procedure. This was further modified by Bolitho in that the Judgment stated that treatment must also be “reasonable” and “logical”. The real sea change came in 2015 in the case of Montgomery Vs Lanarkshire health board. In this case the Judge ruled that the patient must be given enough information on which to make and informed decision. The key words here are informed and information! In this case the Judge ruled that the patient if provided with enough information is capable of weighing up the pros and cons and can take responsibility for their own decisions. This means in practice that the surgeon will and must explain the  procedure and risks in such a way that they can be understood, and  also weigh the % risk to the individual patient. An example would be:- The risk of stiffness in a joint post surgery may be 10%. If the patient was sedentary and limited in daily activity, this risk might not be an issue, however if the patient was a professional athlete, the risk may be unacceptable and the may decline surgery. The risk to both patients although still 10% is weighed very differently. Make sure when you attend for consultation that the risks are fully explained to you!

There is no doubt obesity is on the rise. According to the NHS website obesity affects 1 in 4 adults and 1 in 5 children. Not only can it have an effect on musculoskeletal pain, but significantly increases your risk of diabetes, coronary heart disease and cancer! Patients will often say that they have put weight on because the pain they are experiencing has reduced their ability to exercise, makes sense right!  The real conundrum here is that many musculoskeletal conditions are affected by weight gain and if you are really overweight it can prevent you from having the surgical treatment you need until you lose weight! Of course its understandable that patients will then say; “well I can’t lose weight as I can’t exercise” so around and around we go in a vicious cycle. Ever heard the phrase “a six pack is made in the kitchen not the gym?” well its true! Of course you can put weight on if your exercise ability is reduced… but here is the truth:-Calorie surplus is what causes weight gain not lack of exercise. Of course the more you exercise the higher threshold for your calorie  surplus will be. Therefore the balancing act is to reduce your calorie intake to balance the level of exercise you can do. Although this is a simple fact, its far more complicated to execute for a number of reasons, which may be psychological or be linked to an underlying medical complaint. If you are really struggling with weight, you should see your GP for professional help. The key to weight loss is knowing  exactly how much you eat and drink each day including alcohol, which is a huge source of hidden calories. In fact 1 pint of beer can contain the same calories as a chocolate bar! you can find your calorie deficit point by multiplying your weight in pounds by 10, this is a rough guide however. If you track your food and drink daily by using an app such as MY Fitness Pal, it will help you to understand where you are. Often people feel they eat well and the portion size or the unknown calories in each food is the issue. Hopefully by doing this you will lose weight and you never know, your pain may naturally improve!  Remember no matter what diet plan you choose, whether it is  keto, 5:2, intermittent fasting, slimming world, weight watchers; Track your calories and watch the weight fall off. #weightgain

I have now completed a number of these procedures which have been challenging to say the least. The one step procedure involves breaking the metatarsal and inserting a bone graft. All of the patients experience some stiffness post op which is difficult to avoid. One particular challenge is tendon balance The tendons require a tenotomy to allow for lengthening. The EDL is easy, but the FDL is more difficult. I have attempted to cut at the osteotomy interface, but locating it here is quite difficult. Cutting more distally means that the toe may be unstable. I have been able to reduce the incision size with experience and have made the incision more proximal-this should improve the cosmetic appearance. Generally, the patients do well, however should be cautioned over risks, especially stiffness and plantarflexion of metatarsal. The external fixator technique is simple to apply, but requires patient involvement. This is more protracted and can be frustrating for patients. It seems most patients want the one step procedure. Is this due to their lack of understanding, thinking that it’s much easier!! I have done one case involving a double osteotomy of 3 and 4. The patient did well, but needed a lot of support post op. The fixator bar came loose and had to be replaced under local anaesthetic. Reflection Patients must be cautioned regarding the risks of surgery Expectations need to be managed carefully Time will tell how good the procedure is- there are some issues with gaining length with the one step I intend to visit Dr Lamm, in Florida, at some point to learn his technique #footandankleproblems

Diabetes is certainly on the increase. Type 2 diabetes and its link to obesity is in particular increasing, but what does this have to do with feet? Well, you might be surprised to know that according to NHS England, diabetics with foot ulceration creates an 80% chance of foot amputation, and has a five year mortality, and by that I mean death! of 50%. That means that the mortality rate is similar, or, in some circumstances worse than cancer! That is a very worrying statistic and you should be worried. As a member of the foot protection team in Doncaster and Bassetlaw hospitals, I have first hand experience of helping diabetics. The only problem with this situation is that the condition has usually deteriorated significantly by the time I see a patient. Education and prevention is far better than cure! In fact, if you are diabetic, you should be treating your feet like little princesses with the upmost protection they deserve. The problem is that over time you can loose feeling in the feet and the blood supply can diminish to such an extent that the toes can literally go black and drop off. That’s not good at all! One patient literally found a toe in their sock. The key is to take steps (excuse the pun) to prevent problems. Firstly take control of your glucose management. This will help to prevent some of the foot complications, but the sooner you do this the better. Exercise and watch your diet to lose weight. In some cases, this can reverse early diabetes. Stop smoking, yes, I know you’ve heard it all before, but this without a doubt this will save your circulation! Top tips for better foot health 1. Inspect your feet daily-Do not rely on feel as this may be diminished. 2. Seek attention to any blister or abrasion soon-these can turn into ulcers very quickly 3. Moisturise daily- use ointment like Hydromol. This softens the skin and provides a barrier to infection. 4. Avoid tight shoes or shoes with prominent stitching around the toes- Any area for abrasion may not be felt and can cause damage. 5. Check inside the shoes-remember the sock story above! 6. Do not check bath water with your feet or walk barefoot on hot surfaces- you will burn! 7. Don’t walk bare foot-if you stand on something you might not feel it. 8. Get your feet checked regularly-at least once per year. So I hope that helps and I hope I never see you in the foot protection clinic, but if you need us – call! #diabetes

“The Care I received was the best” “I have received the very best care after numerous operations on both my feet all successfully operated on by Mr Wilkinson. He has completely transformed my feet into what I call Cinderella feet. Not only did I have my operations done by the wonderful NHS but also I paid privately for toes shortening and again the care I received was the best, even I received curtesy calls after to make sure everything was well. I felt very reassured knowing if anything went wrong I could and I did phone park hill hospital and straight away I was reassured and worry resolved. Mr Wilkinson has transformed that part of my life and I am very happy with the results and I will be forever grateful to him.so thank you very much Mr Wilkinson.”