Stabilization of Recurrent Elbow Instability in the Presence of Hyperlaxity in Children Using a Nonanatomic Soft Tissue Reconstruction.

Despite growing concordance of opinion in the adult setting, pediatric elbow instability and its management are poorly represented in the literature due to its low prevalence and often unique circumstances. The authors present a case of posttraumatic recurrent posterior pediatric elbow instability in a patient with joint hypermobility. Our patient, a 9-year-old girl, sustained a right-sided supracondylar fracture of the humerus in April 2019. Having been managed operatively, the elbow remained unstable and dislocated posteriorly in extension. Definitive surgical management was designed to provide a stable functional elbow. The principle of the surgery was to create a checkrein of tissue, not changing in length in extension and flexion, and to prevent further posterior elbow instability. A 3 mm slip of the central triceps tendon was dissected, leaving its attachment to the olecranon tip. Gracilis allograft was sutured to the strip of the triceps tendon to increase the tensile properties of the native tendon graft using a braided nonabsorbable suture. The tendon construct was then passed through a window made in the olecranon fossa and a transosseous tunnel in the ulna from the coronoid tip to the dorsal cortex. The tendon was tensioned and secured to the radial-dorsal aspect of the ulna with a nonabsorbable suture anchor in 90 degrees of flexion. At one year follow-up, the patient has a stable and pain-free elbow joint with no functional limitations.

Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

BACKGROUND: Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees. QUESTIONS/PURPOSES: (1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience? METHODS: We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant. RESULTS: Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively). CONCLUSION: Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations. CLINICAL RELEVANCE: Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

A Face-to-Face Surgical Instrumentation Course During the COVID-19 Pandemic.

Objectives Surgical instrumentation teaching is included as an essential part of surgical training in the core surgical training syllabus. Access to formal teaching is variable, and opportunities for informal teaching have been further reduced by the COVID-19 pandemic. We aimed to design a course to fulfil these local trainees' needs. A move away from face-to-face teaching has occurred successfully during the pandemic, but little literature exists on how face-to-face courses can be best designed during this time. We aimed to describe the practicalities of running a face-to-face course with COVID restrictions. Methods Junior doctors and nurses rotated around five stations led by theatre nurses and senior doctors, each with common instruments from different surgical subspecialties. Social distancing was observed, and level 2 personal protective equipment (PPE) was worn throughout the course. Matched pre- and post-course tests allowed evaluation of learning. Results The course had 20 attendees, and the test scores improved following the course by an average of 9% (p = 0.009). All attendees (100%) found the course improved their knowledge and confidence. Feedback was overwhelmingly positive, and the significant improvement in the multiple-choice question (MCQ) scores demonstrates that this was an effective method of delivering teaching despite the COVID-19 restrictions on social distancing. Conclusion This course shows that instrumentation training is valuable to trainees and provides a good example to other educators, showing the workings of how a practical course may be run face-to-face during the pandemic.

Finger abduction as a novel function of the extensor digitorum brevis manus muscle.

A 25-year-old female presented with a chronic scapho-lunate ligament injury with development of carpal instability requiring reconstruction. During a standard dorsal longitudinal mid-line approach to the carpus, an extensor digitorum brevis manus (EDBM) muscle was found taking its origin from the dorsal wrist capsule overlying the lunate with innervation from the posterior interosseous nerve (PIN). Electrical stimulation of the muscle belly demonstrated abduction of the middle finger. The EDBM is a rare anatomical variant of the extensor compartment of the wrist and may be encountered during surgical approaches. Where possible these variant muscles should be carefully dissected off underlying structures, preserved and repaired at the conclusion of a procedure to ensure no perceived functional deficit to the patient. We present a case of a previously undescribed EDBM muscle function of pure finger abduction with no extension and a surgical technique of preserving its origin. We propose that the middle finger variant of the EDBM should be re-named the extensor digitorum brevis medius to reflect our findings.

Active vs passive haptic feedback technology in virtual reality arthroscopy simulation: Which is most realistic?

BACKGROUND: Virtual Reality (VR) simulators are playing an increasingly prominent role in orthopaedic training and education. Face-validity - the degree to which reality is accurately represented - underpins the value of a VR simulator as a learning tool for trainees. Despite the importance of tactile feedback in arthroscopy, there is a paucity for evidence regarding the role of haptics in VR arthroscopy simulator realism. PURPOSE: To assess the difference in face validity between two high fidelity VR simulators employing passive and active haptic feedback technology respectively. METHOD: 38 participants were recruited and divided into intermediate and expert groups based on orthopaedic training grade. Each participant completed a 12-point diagnostic knee arthroscopy VR module using the active haptic Simbionix ARTHRO Mentor and passive haptic VirtaMed ArthroS simulators. Subsequently, each participant completed a validated simulator face validity questionnaire. RESULTS: The ARTHRO Mentor active haptic system failed to achieve face validity with mean scores for external appearance (6.61), intra-articular appearance (4.78) and instrumentation (4.36) falling below the acceptable threshold (≥7.0). The ArthroS passive haptic simulator demonstrated satisfactory scores in all domains: external appearance (8.42), intra-articular appearance (7.65), instrumentation (7.21) and was significantly (p < 0.001) more realistic than ARTHRO Mentor for all metrics. 61% of participants gave scores ≥7.0 for questions pertaining to haptic feedback realism from intra-articular structures such as menisci and ACL/PCL for the ArthroS vs. 12% for ARTHRO Mentor. There was no difference in face-validity perception between intermediate and expert groups for either simulator (p > 0.05). CONCLUSION: Current active haptic technology which employs motors to simulate tactile feedback fails to demonstrate sufficient face-validity or match the sophistication of passive haptic systems in high fidelity arthroscopy simulators. Textured rubber phantoms that mirror the anatomy and haptic properties of the knee joint provide a significantly more realistic training experience for both intermediate and expert arthroscopists.

Validation of a Virtual Reality Simulator for Percutaneous Pedicle Screw Insertion.

INTRODUCTION: Working-hour restrictions, rota gaps and an increasing drive for theatre efficiency have resulted in challenges to surgical training. As a result, Virtual Reality (VR) has emerged as a popular tool to augment this training. Our aim was to evaluate the validity of a VR simulator for performing percutaneous pedicle screw guidewire insertion. MATERIALS AND METHODS: Twenty-four participants were divided into three equal groups depending on prior surgical experience: a novice group (<10 procedures), an intermediate group (10-50 procedures) and an expert group (>50 procedures). All subjects performed four guidewire insertions on a TraumaVision® simulator (Swemac Innovation AB, Linköping, Sweden) in a set order. Six outcome measures were recorded; total score, time, fluoroscopy exposure, wire depth, zone of placement and wall violations. RESULTS: There were statistically significant differences between the groups for time taken (p<0.001) and fluoroscopy exposure (p<0.001). The novice group performed the worst, and the expert group outperformed both intermediates and novices in both categories. Other outcome results were good and less variable. There was an observed learning effect in the novice and intermediate groups between each of the attempts for both time taken and fluoroscopy exposure. CONCLUSIONS: The study contributes constructive evidence to support the validity of the TraumaVision® simulator as a training tool for pedicle screw guidewire insertion. The simulator is less suitable as an assessment tool. The learning effect was evident in the less experienced groups, suggesting that VR may offer a greater benefit in the early stages of training. Further work is required to assess transferability to the clinical setting.

Reducing the Risk and Impact of Brachial Plexus Injury Sustained From Prone Positioning-A Clinical Commentary.

INTRODUCTION: Prone positioning is deployed as a critical treatment for improving oxygenation in patients with Acute Respiratory Distress Syndrome. This regimen is currently highly prevalent in the COVID-19 pandemic. The pandemic has brought about increased concern about how best to safely avoid brachial plexus injuries when caring for unconscious proned patients. METHODS: A review of the published literature on brachial plexus injuries secondary to proning ventilated patients was performed. This was combined with a review of available international critical care guidelines in order to produce a succinct set of guidelines to aid critical care departments in reducing brachial plexus injuries during these challenging times. DISCUSSION: There is no one manner in which prone positioning an unconscious patient can be made universally safe. This paper provides 6 key steps to reducing the incidence of brachial plexus injuries while proning and suggests a safe and sensible management and referral pathway for the conscious patient in which a brachial plexus injury is identified. CONCLUSION: There is in truth no completely safe position for every patient and certainly there will be anomalies in anatomy that will predispose certain individuals to nerve injury. Thus the injury rate cannot be reduced to zero but an understanding of the principles of protection will inform those undertaking positioning.

Transferable Global Rating Scales in the Validation of the ArthroSim™ Virtual Reality Arthroscopy Simulator.

INTRODUCTION: Virtual reality arthroscopic simulators are becoming increasingly prevalent in the orthopaedic training environment. The construct validity of the ArthroSim virtual reality simulator (TolTech Touch of Life Technologies, Aurora, Colorado) has been established based on time to completion comparison between candidates of differing levels of surgical experience. This study aims to establish the construct validity of the ArthroSim virtual reality simulator using validated global rating scales that allow direct comparison with intraoperative performance. MATERIALS AND METHODS: Eight novices (medical students), eight intermediates (registrars), and seven experts (consultants) were assessed using the Imperial Global Arthroscopy Rating Scale (IGARS) and the Arthroscopic Surgical Skills Evaluation Tool (ASSET) scoring systems while carrying out a standardised basic diagnostic knee arthroscopy using linked and anonymised recordings of both the arthroscopy video output and candidate's hand posture and position. Time to completion was recorded and the expert group also filled out questionnaires assessing the face and content validity of the simulator. RESULTS: The mean IGARS/ASSET scores for the novice, intermediate and expert groups were 14/11, 29/22, and 46/36 respectively. The difference in score between each of the groups was statistically significant (p<0.05). The average time to completion was 257 seconds, 305 seconds, and 204 seconds respectively. The time to completion was not significantly different between the groups (p=0.6). CONCLUSIONS: The ArthroSim virtual reality simulator could effectively distinguish between candidates of differing experience levels using validated global rating scales and therefore demonstrated construct validity.

Distal radius fractures: an evidence-based approach to assessment and management.

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review.

PURPOSE: To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures. METHODS: A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded. RESULTS: A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies. CONCLUSIONS: Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment. LEVEL OF EVIDENCE: Level III, systematic review of level I to III studies.

Biomechanical Study Comparing Cut-out Resistance of the X-Bolt® and Dynamic Hip Screw at Various Tip-Apex Distances.

BACKGROUND: Bone quality in hip fractures is poor and there is a need to not only correctly position metalwork within the femoral head, but also for implants to resist cut-out. New implant designs may help to reduce metalwork cut-out, leading to fewer failures of fixation. This study compared the cut-out strength of a Dynamic Hip Screw (DHS) to that of an X-Bolt® (X-Bolt Orthopaedics, Dublin, Ireland) implant in an osteoporotic Sawbones® (Sawbones, Vashon Island, WA) model. METHODS: An unstable fracture model (AO 31-A2) was created using low-density 5 pound per cubic foot (pcf) Sawbones®. The DHS and X-Bolts® were inserted into the Sawbones® femoral head at Tip-Apex Distances (TAD) of 10mm, 15mm, 20mm, 25mm, 30mm and 40mm. A cyclic-loading Instron® machine (Instron Corp., Norwood, MA) pushed the bone at a compression rate of 5mm per minute at a 20-degree angle to the axis of the implant with an upper force limit of 4000N. Maximum force reached and load to failure, defined as movement of the implant by 5mm, were recorded. Four implants were used per group to give a total of 48 tests between the two groups. RESULTS: The X-Bolt® demonstrated a superior average maximum total load push-out force compared to the DHS group for all of the TAD configurations tested. The maximum force reached in the X-Bolt® group was significantly higher than that in the DHS group at a TAD of 10mm (X-Bolt® 3299.25N vs. DHS 2843.75N, P<0.029) and 30mm (X-Bolt® 2908.25N vs. DHS 2030N, P<0.029). The X-Bolt® also had a higher load to failure than the DHS group at all of the TAD values tested. CONCLUSIONS: The X-Bolt® implant gave superior performance compared to the standard DHS, as reflected by a greater push-out force in an osteoporotic Sawbones® model.

Treating the Many Using a Few: A Novel Approach for the Application of External Fixators in Mass Casualties.

AIM: The aim of this is to allow the use of unsterile kit (clamps and rods) in situations where the demand for external limb fixators exceeds the available sterile equipment. BACKGROUND: In view of the recent rise in violence and terrorist activity, we have to be prepared for situations causing major incidences. These can place a large strain on our operating theaters and the available surgical kit due to the potential number of casualties. MATERIALS AND METHODS: We propose a sterile dressing technique during the application of an external limb fixator that provides an adequate seal around the pin sites and allows the use of simply decontaminated external fixator parts. CONCLUSION: This technique prevents the intraoperative contamination of the clamps and connecting rods, which allow for a sterile barrier to minimize pin site infections. HOW TO CITE THIS ARTICLE: Vris A, Al-Obaedi O, Vaghela KR, et al. Treating the Many Using a Few: A Novel Approach for the Application of External Fixators in Mass Casualties. Strategies Trauma Limb Reconstr 2019;14(2):92-93.

Performance on a Virtual Reality DHS Simulator Correlates with Performance in the Operating Theatre.

INTRODUCTION: Dynamic Hip Screw (DHS) fixation of neck of femur fractures is one of the most commonly performed orthopaedic trauma operations. Changes in working practices have impacted surgical training and have resulted in fewer opportunities to perform this procedure. Virtual reality (VR) simulation has been shown to be a valid means of gaining competency, efficiently and safely, without compromising patient safety. OBJECTIVE: The aim of this study is to determine whether performance on a VR DHS simulator correlates with performance in the operating theatre. MATERIALS AND METHODS: All episodes of DHS fixation of neck of femur fractures performed at Royal London Hospital, Barts Health NHS Trust, level 1 major trauma centre between January 2014 and December 2015 were identified using the hip fracture database. The primary surgeon was identified using the electronic operative notes. The intraoperative fluoroscopic images were accessed and the tip-apex distance (TAD) was measured, as well as the probability of cut-out. The surgeon then performed DHS fixation on a VR DHS simulator and the TAD achieved in theatre was correlated with the simulated TAD. RESULTS: Twenty-five surgeons, including six novices (core surgical trainees), 12 intermediates (specialist registrars), and seven experts (fellows and consultants), completed the study. There was no overall statistically significant difference in TAD between those achieved in the operating theatre and on the simulator for each participant (p=0.688). CONCLUSION: There is no significant difference between performance on a VR DHS simulator and the operating theatre. This suggests that the simulator is excellent for training in this component of the DHS procedure, but further work is needed to assess whether training on the simulator can improve performance in the operating theatre.

Hemi-Hamate Autograft Arthroplasty for the Proximal Interphalangeal Joint Revisited: A New Surgical Approach.

The hemi-hamate arthroplasty for proximal interphalangeal joint (PIPJ) dorsal fracture dislocations relies on complete dislocation of the joint using the 'shotgun' approach which provides excellent exposure but damages the delicate intrinsic joint stabilisers. We present a new approach to the PIPJ when performing the hemi-hamate arthroplasty. The volar surgical approach involves freeing up the whole tendon sheath-periosteal unit as a single layer, and retracting this to one side. The articular surface of the joint can then be accessed with a little distraction and hyperextension. The method does not breach the tendon sheath, nor does it damage the collateral ligaments or volar plate. It is akin to the radical total anterior teno-arthrolysis (TATA) technique used for contracted joints, with some crucial differences. We postulate that the new approach causes far less iatrogenic damage and reduces the risk of contractures developing, and in chronic cases, allows concurrent joint release.

Syndesmosis preserving osteotomy of the fibula for access to the lateral talar dome.

BACKGROUND: Open surgical access to the postero-lateral talar dome for the treatment of osteochondral lesions is challenging, often requiring a segmental osteotomy of the fibula (fibular window) and division of the anterior inferior tibiofibular ligament (AITFL) or a fibular osteotomy with division of the AITFL and the anterior talofibular ligament (ATFL) (fibular door). Alternatively, to preserve the tibiofibular syndesmosis both the fibula and the lateral tibial plafond can be osteotomised to expose the entire lateral talar dome. All of these techniques involve extensive surgical exposures and a significant amount of internal fixation of the osteotomy to achieve surgical access. METHODS: A trapezoidal fibular osteotomy which hinges on the AITFL thus preserving the syndesmotic and lateral ligamentous complex was developed to permit perpendicular access to the lateral talar dome. The remaining posterior column of fibula allows keying in of the osteotomy requiring minimal internal fixation. RESULTS: A 43 year old male with a displaced osteochondral fracture of the superolateral talar dome underwent the osteotomy to provide perpendicular fixation with two Herbert's screws. The osteotomy was reduced and fixed with a single 3.5mm lag screw. At 3 month follow up the osteotomy had healed both clinically and radiographically. CONCLUSIONS: Our technique utilizes a novel trapezoidal fibular osteotomy with preservation of key syndesmotic and ligamentous structures and requires minimal internal fixation.

Severe destructive arthritis of the carpometacarpal joint: a diagnosis of exclusion case report.

We present a case of severe destruction of the thumb carpometacarpal joint (CMCJ) and surrounding structures on a background of osteoarthritis and Seronegative Rheumatoid arthritis. Imaging studies suggested a soft tissue lesion consistent with Pigmented Villonodular Synovitis (PVNS), Synovial Osteochondromatosis or Giant Cell Tumour (GCT). Due to the possibility of malignant transformation and deteriorating symptoms the mass was excised. Histological analysis of the lesion revealed severe degenerative disease with no evidence of malignancy or infection. This represents an atypical presentation of thumb carpometacarpal joint arthritis, which should be diagnosed once more sinister pathology has been excluded.

Plastic surgery and burns disasters. What impact do major civilian disasters have upon medicine? Bradford City Football Club stadium fire, 1985, King's Cross Underground fire, 1987, Piper Alpha offshore oil rig disaster, 1988.

Major disasters involving multiple casualties are neither new nor infrequent. Such events have important implications for medicine and can provide crucial lessons for the future. However, while the medical aspects of war have received considerable attention, rather less is known about civilian disasters. To redress this imbalance, this article reviews three major British disasters of the 1980s where serious burns injury was a significant feature of the human casualty: the Bradford City Football Club fire of 1985, the King's Cross Underground fire of 1987 and the Piper Alpha oil rig disaster of 1988. Four related themes are used to examine in detail the ways in which these events impacted on medicine: plastics and reconstructive surgery, clinical psychology, disaster management and long-term structural change. Drawing on articles in specialist burns and psychiatric journals, together with the personal communications and recollections of surgeons and psychiatrists involved, it is revealed that while ground-breaking advances are a relative rarity in medicine, numerous small but significant lessons did emerge from these events, although often in subtle and highly specialised fields of medicine.