Differential attainment, socioeconomic factors and surgical training.

INTRODUCTION: Differential attainment (DA) is the gap in levels of achievement between different groups; socioeconomic factors are thought to play a significant role in DA. The aim of this study was to review and assess the evidence for DA in early surgical training and to examine the potential influence of socioeconomic status. METHODS: Data were obtained from the General Medical Council GMC for those taking Membership of the Royal College of Surgeons (MRCS) examinations between 2016 and 2019 and core surgical training annual review of competency progression (ARCP) outcomes between 2017 and 2019. The index of multiple deprivation (IMD) was used as a measure of socioeconomic background. Trainees were then divided into deprivation quintiles (DQ1=most deprived, DQ5=least deprived). MRCS and ARCP outcomes were compared between DQ groups using 95% confidence intervals and chi-square tests. RESULTS: Those from lower socioeconomic backgrounds had significantly lower overall MRCS pass rates (DQ1=45.5%, DQ2=48.9% vs DQ4=59.6%, DQ5=61.5%, p<0.05) and 1st time pass rates (DQ1&2=46.6% vs DQ4&5=63.5%, p<0.001). Additionally, they had a significantly higher number of attempts required to pass MRCS (DQ 1&2=1.86 vs DQ 4&5=1.54, p<0.01). Those from lower socioeconomic backgrounds had a significantly greater proportion of unsatisfactory ARCP outcomes (DQ1&2=24.4% vs DQ 4&5=14.2%, p<0.05). CONCLUSIONS: There is clear evidence of the influence of socioeconomic background on DA in early surgical training. However, the reasons for this are likely complex and more work is required to investigate this relationship.

Defining reference levels for intra-operative radiation exposure in orthopaedic trauma: A retrospective multicentre study.

There is currently limited data to define reference levels for the use of ionising radiation in orthopaedic trauma surgery. In this multicentre study, we utilise methodology employed by the Health Protection Agency in establishing reference levels for diagnostic investigations in order to define analogous levels for common and reproducible orthopaedic trauma procedures. Four hundred ninety-five procedures were identified across four Greater London hospitals over a 1-year period. Exposure was defined in terms of both time and dose area product (DAP). Third quartile mean values for either parameter were used to define reference levels. Variations both between centres and grades of lead surgeon were analysed as secondary outcomes. Reference levels; dynamic hip screw (DHS) 1.9225000 Gycm(2)/70.50 s, intramedullary (IM) femoral nail 1.5837500 Gycm(2)/126.00 s, open reduction internal fixation (ORIF) clavicle 0.2042500 Gycm(2)/21.50 s, ORIF lateral malleolus 0.32250500 Gycm(2)/35.00 s, ORIF distal radius 0.1300000 Gycm(2)/56.00 s. Grade of surgeon did not influence exposure in dynamic hip screw, and was inversely related to exposure in intramedullary femoral nails. Less variation was observed with exposure time than with DAP. This study provides the most comprehensive reference to guide fluoroscopy use in orthopaedic trauma to date, and is of value both at the point of delivery and for audit of local practice.

Long-term patient-reported outcomes following Bennett's fractures.

We define the long-term outcomes and rates of further operative intervention following displaced Bennett's fractures treated with Kirschner (K-) wire fixation between 1996 and 2009. We retrospectively identified 143 patients (127 men and 16 women) with a mean age at the time of injury of 33.2 years (18 to 75). Electronic records were examined and patients were invited to complete the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in addition to a satisfaction questionnaire. The time since injury was a mean of 11.5 years (3.4 to 18.5). In total 11 patients had died, one had developed dementia and 12 patients were lost to follow-up. This left 119 patients available for recruitment. Of these, 57 did not respond, leaving a study group of 62 patients. Patients reported excellent functional outcomes and high levels of satisfaction at follow-up. Median satisfaction was 94% (interquartile range 91.5 to 97.5) and the mean DASH score was 3.0 (0 to 38). None of the patients had undergone salvage procedures and none of the responders had changed occupation or sporting activities. Long-term patient reported outcomes following displaced Bennett's fractures treated by closed reduction and K-wire fixation show excellent functional results and a high level of patient satisfaction. The rate of infection is low and similar to other surgical procedures with percutaneous K-wires.

Nonunion after trapeziometacarpal arthrodesis: comparison between K-wire and internal fixation.

We reviewed 63 trapeziometacarpal arthrodeses (57 patients) performed in our unit between April 2007 and May 2013 for osteoarthritis. K-wires, plates, headless compression screws and memory staples were used for fixation. The average age of patients was 50 (range 20-78) years and there were 36 men and 21 women with a mean follow-up of 36 (range 6-62) months. K-wires were used in 31 cases, staples in 12, plates in five, and screws in 15 joints. The overall non-union rate was 11%, however, when using K-wires for fixation, it was 20%. Union was achieved in all cases when staples or screws were used for fixation. Disabilities of the Arm, Shoulder and Hand scores were higher in cases where non-union occurred compared with those that united (66.7 vs. 21.9). Trapeziometacarpal arthrodesis for osteoarthritis gives good clinical outcome with lower (DASH) scores when union occurs. K-wire fixation led to a 20% non-union rate, and as a result, the senior author no longer uses this method of fixation.

Variability in local pressures under digital tourniquets.

The UK National Patient Safety Agency issued a rapid response report in 2009 following reports of complications related to digital tourniquet use and inadvertent retention. In their guidance, they recommend the use of CE marked digital tourniquets and advise against the use of surgical gloves. There are a number of different commercially available non-pneumatic digital tourniquets, but little clear data relating to their comparable physical properties, clinical efficacy or safety. The aim of this study was to investigate the variability of pressures exerted by non-pneumatic digital tourniquets. A Tekscan FlexiForce(®) force sensor was used to measure applied force and to calculate the surface pressures under: the Toe-niquet™; T-Ring™ and surgical glove 'roll down' tourniquets in finger models. The lowest mean pressures were produced by the larger glove sizes (size 8) (25 mmHg), while the highest pressures were produced by the Toe-niquet (1560 mmHg). There was a significant overall difference in pressures exerted under tourniquets when comparing tourniquet type (p<0.001) and finger size (p<0.001) with these techniques. It is difficult to anticipate and regulate pressures generated by non-pneumatic tourniquets. Safe limits for application time and surface pressures are difficult to define. Further work is required to model the pressure effects of commercially available digital tourniquets and to identify which are most effective but safe.

Tensioning of Prolene reduces creep under cyclical load: relevance to a simple pre-operative manoeuvre.

A longitudinal stretch or 'pre-tensioning' is a method employed by some surgeons to improve the handling characteristics of a suture. We used a tensile tester to assess the effect of pre-tensioning on the mechanical properties of two suture materials (3-0 Prolene and 3-0 Ethibond) commonly used for flexor tendon repair. A cyclical loading programme was used to simulate an early rehabilitation regime. All sutures were subsequently tested to failure (for ultimate tensile strength). The pre-tensioned Prolene sutures showed significantly less creep after cyclical loading in comparison to controls. Conversely pre-tensioning had no measurable effect on the deformation of Ethibond by creep. There was no effect on ultimate tensile strength for either material. The propensity of Prolene to creep (and thereby form a 'gap' in tendon repairs) can be reduced by pre-tensioning.

Black bone disease of the foot. Minocycline related pigmentation.

Black bone disease is a rare manifestation of long term treatment with tetracyclines. We report the case of a patient who underwent surgery for bilateral hallux valgus and was found to have black discolouration of both first rays. This was subsequently related to previous long term Minocycline use. The unique features of this case relate to the location of the discolouration and the normal physical properties of the bone and soft tissues at surgery despite heavy pigmentation. Healing is now complete and follow-up at two years confirmed excellent clinical and radiological outcomes.

The epidemiology of fractures of the hand and the influence of social deprivation.

This study investigates the relationship between the epidemiology of hand fractures and social deprivation. Data were collected prospectively in a single trauma unit serving a well-defined population. The 1382 patients treated for 1569 fractures of the metacarpals or phalanges represented an incidence of hand fracture of 3.7 per 1000 per year for men and 1.3 per 1000 per year for women. Deprivation was not directly associated with the incidence of hand fracture. Common mechanisms of injury are gender specific. Fractures of the little finger metacarpal were common (27% of the total) and were associated with social deprivation in men (P = 0.017). For women, fractures where the mechanism of injury was unclear or the patient was intoxicated and could not recall the mechanism showed a clear association with deprivation. Affluent patients were more likely to receive operative treatment. Social deprivation influences both the pattern and management of hand fractures.

Osteoporotic periprosthetic fractures of the femur in elderly patients: outcome after fixation with the LISS plate.

Longer patient survival and the extension of joint arthroplasty to older patients means that osteoporotic fractures of the femur are often associated with joint implants. This poses a significant trauma work load. This problem is likely to increase over time. The management of these periprosthetic fractures may be difficult and strategies are not universally agreed. Revision arthroplasty, single or double plate fixation with or without augmentation with methylmethacrylate or bone grafting, are all variously advocated in the literature for different indications. We retrospectively identified 28 elderly patients consecutively treated in our institution with Less Invasive Stabilisation System (LISS) plate fixation for osteoporotic and periprosthetic fractures of the femur. We present prospectively collected data for clinical and radiographic follow-up and patient outcomes. Patients had a mean age of 86.7 years. A fall from a standing height was the most common mechanism of injury. No cases of non-union were seen in survivors. Mortality in the first year was a major complication (5 patients). Rates of revision surgery were low (2 patients). Most patients required a formal period of rehabilitation, however, only half of the patients were successfully discharged to their own homes. The LISS plate provides good fixation in osteoporotic periprosthetic fractures of the femur. It restores a stable limb allowing early weight bearing as well as achieving clinical and radiographic union. Patients return to mobility levels approaching their pre-injury status although most benefit from a formal period of rehabilitation. In this patient group, the LISS plate often outlives the patient.

Grip strength and forearm circumference in a healthy population.

Two hundred and fifty subjects were recruited. Age, sex, hand preference and anthropometric measurements were recorded for each subject. Grip strength was measured using a Jamar hydraulic dynamometer. Multiple regression analyses were performed. One hundred and seventy two subjects were men and 78 were women. Twenty-six subjects were left hand dominant. Hand grip strength was greatest for the 35 to 44 year old group for both sexes. Grip strength was consistently greater for men than women. Contralateral grip strength predicted maximum grip strength for both sexes. Forearm circumference predicted maximum hand grip strength for men. Although there was a large range of forearm circumferences in the population, there was little difference between sides for each subject (100% less than 2 cm). The demonstrated relationships between: (i) contralateral grip strengths and (ii) grip strength and forearm circumference lead us to suggest that for certain pathologies, a difference in forearm circumference greater than 2 cm may lend credence to a measurement of diminished grip strength.

Hand injuries at a British Military Hospital on operations.

The nature of military medical support necessarily changes in the transition from war fighting to the post-conflict phase. This paper examines the activity in the only British Military Hospital serving a multi-national divisional area in Iraq over 2004 during this post-conflict phase. Hand injuries were common and formed a large proportion of the workload seen at the military field hospital on operations. The overwhelming majority of hand trauma resulted in soft tissue injury. There was a clear predisposition to hand trauma for males, manual workers, combat soldiers and engineers/mechanics. While most hand injuries do not require surgical intervention, they impact on the effectiveness of the military population as a result of the large proportion of patients who are placed on restricted duties following hand trauma, 157 of 241 in this study, and the number of soldiers who require aeromedical evacuation for further treatment, 38 of 360 in this study. These injuries require that military surgeons and emergency physicians should be experienced in the initial management of hand trauma and hand trauma should be a core component of their training. The skills of the specialist hand surgeon may be required for definitive management of these injuries at a later stage.

The management of head injuries on military operations.

The management of head injured patients has recently been reviewed with the development of civilian guidelines for best practice. These are common injuries which often have significant sequelae for patients and costs for health care providers. Evolving civilian standards of care have implications for military medicine which is often practised in challenging environments. Considerable planning and resources are necessary to meet these standards in an operational environment. The current standards and the problems of applying them in an operational theatre are discussed.

Informed consent and the JHO in Scotland.

AIM: To define the views of junior house-officers (JHOs) concerning consent for general surgical conditions. METHODS: Questionnaire-based descriptive study on two cohorts of JHOs, separated by 3 years of major national and local directives. RESULTS: From the JHO perspective: (i) there has been a shift away from the JHO being the main signatory, (ii) many JHOs (58% in 2000; 47% in 2003) feel unsupported with respect to obtaining consent, (iii) knowledge concerning any consultant/unit's complication rates was poor (<30%), (iv) knowledge concerning complication rates for several paradigm procedures was also poor, though it improved from 2000 to 2003, (v) there is no formal training in consent. CONCLUSIONS: Despite the JHO group of 2003 outperforming that of 2000, there is major scope for improvement from patient, legal, educational and risk-management perspectives.

Would women trust their partners to use a male pill?

Despite a renewed interest in the development of hormonal contraceptives for men, many discussions about the potential acceptability of a 'male pill' end by speculating whether women would trust their partners to use the method reliably. To determine the views of women, we undertook a survey of 1894 women attending family planning clinics in Scotland (450), China (900) and South Africa (544). In all centres over 65% of women thought that the responsibility for contraception falls too much on women. More than 90% in South Africa and Scotland thought that a 'male pill' was a good idea, with Chinese women (71% in Hong Kong and 87% in Shanghai) only slightly less positive. Only 13% of the total sample did not think that hormonal male contraception was a good idea and only 36 women (2% of the total) said that they would not trust their partner to use it. 78% of Scottish women, 71% of Shanghai women, and 78% of white women and 40% of black and coloured women in Cape Town thought that they would use the method. This survey should dispel the myth that women would not trust their partners to use a 'male pill' reliably and illustrates the potential market for the method.