Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration.

BACKGROUND: Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers. METHODS: This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol. RESULTS: After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective. CONCLUSION: Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

Cost-effectiveness of treatments for superficial venous reflux in patients with chronic venous ulceration.

BACKGROUND: Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost-effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration. METHODS: A Markov decision analytical model was developed. The main outcome measures were quality-adjusted life-years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound-guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta-analysis of RCTs. RESULTS: Surgery gained 0·112 (95 per cent c.i. -0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €-1330 (-3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions. DISCUSSION: This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS.

Graduated Compression Stockings as an Adjunct to Low Dose Low Molecular Weight Heparin in Venous Thromboembolism Prevention in Surgery: A Multicentre Randomised Controlled Trial.

BACKGROUND: The evidence base upon which current global venous thromboembolism (VTE) prevention recommendations have been made is not optimal. The cost of purchasing and applying graduated compression stockings (GCS) in surgical patients is considerable and has been estimated at £63.1 million per year in England alone. OBJECTIVE: The aim was to determine whether low dose low molecular weight heparin (LMWH) alone is non-inferior to a combination of GCS and low dose LMWH for the prevention of VTE. METHODS: The randomised controlled Graduated compression as an Adjunct to Pharmacoprophylaxis in Surgery (GAPS) Trial (ISRCTN 13911492) will randomise adult elective surgical patients identified as being at moderate and high risk of VTE to receive either the current "standard" combined thromboprophylactic LMWH with GCS mechanical thromboprophylaxis, or thromboprophylactic LMWH pharmacoprophylaxis alone. To show non-inferiority (3.5% non-inferiority margin) for the primary endpoint of all VTE within 90 days, 2236 patients are required. Recruitment will be from seven UK centres. Secondary outcomes include quality of life, compliance with stockings and LMWH, overall mortality, and GCS or LMWH related complications (including bleeding). Recruitment commenced in April 2016 with the seven UK centres coming "on-line" in a staggered fashion. Recruitment will be over a total of 18 months. The GAPS trial is funded by the National Institute for Health Research Health Technology Assessment in the UK (14/140/61).

Treatment decisions for descending thoracic aneurysm: preferences for thoracic endovascular aneurysm repair or surveillance in a discrete choice experiment.

OBJECTIVE: To investigate and rank factors that influence endovascular treatment decisions by specialists for patients with descending thoracic aortic aneurysm (dTAA). METHODS: Specialists completed a diagrammatic survey describing uncertainty about the benefit of thoracic endovascular aneurysm repair (TEVAR) for dTAA with respect to age, sex, and aneurysm diameter. Subsequently, a detailed discrete choice experiment was designed. Specialists were recruited and asked to indicate treatment their preference (TEVAR or surveillance) in 25 hypothetical cases of dTAA, with variable patient attributes: age, sex, American Society of Anesthesiologists (ASA) grade, aneurysm diameter, adequate landing zone distal to left subclavian artery (LSA), and length of aortic coverage. Data were analysed using multiple logistic regression. RESULTS: The diagrammatic survey, based on 50 respondents, showed that uncertainty about the benefits of TEVAR was greatest for patients aged 80-85 years (up to 47% of respondents were "unsure") and that uncertainty increased with increasing aneurysm diameter (for an 80-year-old man, 7% were unsure at 5.5 cm and 33% were unsure at 7.0 cm). Seventy-one specialists (mainly from Europe and North America, 86% vascular surgeons and 98% working in units offering TEVAR) completed the discrete choice experiment. Preference for TEVAR increased greatly with enlarging diameter: adjusted odds ratios (OR) >5.5-6.0 cm = 15.8 (95% confidence interval [CI] 9.83-25.40); >6.0-6.5 cm = 393.0 (95% CI 202.00-766.00); >6.5-7.0 cm = 1829.0 (95% CI 400.00-4,181.00). TEVAR was less likely to be preferred in patients older than 75 years (>75-80 years OR 0.32, 95% CI 0.21-0.49; >80-85 years = 0.18, 95% CI 0.11-0.28); in women (OR 0.52, 95% CI 0.37-0.74); in patients classified as ASA grade 4 (OR 0.44, 95% CI 0.36-0.57); and in patients with aorta coverage >25 cm (OR 0.48, 95% CI 0.32-0.74). The proximal landing zone did not influence preference. CONCLUSION: Specialists' preferences for endovascular repair of degenerative dTAA vary widely, and demonstrate clinical uncertainty, especially in octogenarians, and a reluctance to offer TEVAR to women. Aneurysm diameter dominates treatment preferences, but patient fitness and length of aortic coverage (>25 cm) also were influential, although the landing zone distal to LSA was not.

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm.

BACKGROUND: Single-centre series of the management of patients with ruptured abdominal aortic aneurysm (AAA) are usually too small to identify clinical factors that could improve patient outcomes. METHODS: IMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair (EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors. RESULTS: Some 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio (OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30-day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70). CONCLUSION: These findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension.

The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: A five-year prospective study.

OBJECTIVES: To assess the effectiveness of a modified tibial tubercle osteotomy as a treatment for arthroscopically diagnosed chondromalacia patellae. METHODS: A total of 47 consecutive patients (51 knees) with arthroscopically proven chondromalacia, who had failed conservative management, underwent a modified Fulkerson tibial tubercle osteotomy. The mean age was 34.4 years (19.6 to 52.2). Pre-operatively, none of the patients exhibited signs of patellar maltracking or instability in association with their anterior knee pain. The minimum follow-up for the study was five years (mean 72.6 months (62 to 118)), with only one patient lost to follow-up. RESULTS: A total of 50 knees were reviewed. At final follow-up, the Kujala knee score improved from 39.2 (12 to 63) pre-operatively to 57.7 (16 to 89) post-operatively (p < 0.001). The visual analogue pain score improved from 7.8 (4 to 10) pre-operatively to 5.0 (0 to 10) post-operatively. Overall patient satisfaction with good or excellent results was 72%. Patients with the lowest pre-operative Kujala score benefitted the most. Older patients benefited less than younger ones. The outcome was independent of the grade of chondromalacia. Six patients required screw removal. There were no major complications. CONCLUSIONS: We conclude that this modification of the Fulkerson procedure is a safe and useful operation to treat anterior knee pain in well aligned patellofemoral joints due to chondromalacia patellae in adults, when conservative measures have failed.

Bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia.

The gluteal compartment syndrome is uncommon and is discussed in only a few published case reports. The simultaneous bilateral gluteal compartment syndrome is exceptionally rare and is tackled in only 4 case reports to date. We report a case of bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia and discuss its management.

Observations of subchondral plate advancement during osteochondral repair: a histomorphometric and mechanical study in the rabbit femoral condyle.

OBJECTIVE: The subchondral plate and its reconstitution has been an under-researched aspect of articular cartilage repair. The extent to which the subchondral plate is restored by natural healing remains controversial. This study aimed to quantify advancement of subchondral bone during repair of an osteochondral defect, and to examine the effect of subchondral bone height on the quality of articular surface repair. DESIGN: Osteochondral defects, 3mm diameter by 3mm deep, were made by controlled drilling through the articular surface into the subchondral bone in femoral condyles of 33 rabbits. The repair response was examined at 8, 16 and 32 weeks (n=14, 12 and 7, respectively) post surgery. The specimens were subjected to mechanical testing, radiography, histology and histomorphometrology using an image analysis system. RESULTS: At 8 weeks, the level of reparative subchondral bone was 0.79+/-0.36 mm below the native tidemark. By 16 weeks, reformed subchondral plate was irregular, showing that 76.5% of the plate had extended beyond the native tidemark (0.13+/-0.05 mm) whilst 16.9% of the plate remained below (0.19+/-0.15 mm). The repaired surface non-osseous layer became thinner than the adjacent cartilage (0.23+/-0.08 vs 0.38+/-0.11 mm, P<0.05). This persisted up to 32 weeks. The repaired surface layers showed disappearance of safranin-O staining, increased separation splits at the boundary, and eventual degradation. General histological scores were similar across 8, 16 and 32 weeks although the scores of defect filling and restoration of osteochondral junction were decreased from 8 to 16 weeks. Mechanically, repaired defects had lower contact pressure and greater indentation than the normal controls at all time (P<0.05). Indentations of the cartilage adjacent to the defects were also greater than the normal at 8 and 32 weeks (P<0.05). CONCLUSION: The reparative subchondral bone advanced beyond the level of the native subchondral plate by 16 weeks in osteochondral defects of the rabbit femoral condyles. The presence of an advanced and irregular subchondral plate was associated with degradation of repaired articular surface. Abnormal subchondral plate is likely one of the major factors in influencing the long-term outcome of articular cartilage repair.

Evaluation of Gateshead carbon fibre rod as an implant material for repair of osteochondral defects: a morphological and mechanical study in the rabbit knee.

Use of the Gateshead carbon fibre rod system remains controversial. Although it has been shown to enhance the repair of lesions in load bearing areas of convex articular surfaces, there is a lack of evidence to support the claim that it provides an inert scaffold for ingrowth of organised fibrous tissue. and thereby increasing the rate and quality of articular surface regeneration. This study examined osteochondral repair following implantation of a Gateshead rod in the femoral condyles of 25 rabbits for up to 32 weeks. using radiology, histology, scanning electron microscopy and mechanical testing. The repaired fibrocartilaginous surface layer was found to be persistently softer than the normal control and some repaired surfaces were worn, exposing the rod at 32 weeks. Whilst fibrous tissue grew into the outer braided sheath of the rod, the core remained impervious. The rod appeared to act as a space occupier, initially providing better subsurface support than found in natural healing. In the long term, however, it prevented subchondral bone restoration and re-establishment of the normal osteochondral junction, resulting in a quality of repair which did not differ from that found in naturally healing defects.

The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint.

OBJECTIVES: This study considered the role of magnetic resonance imaging (MRI) in the diagnosis of knee injuries in a district general hospital (DGH) setting. The principal objective was to identify whether the use of MRI had a major impact on the clinical management of patients presenting with chronic knee problems, in whom surgery was being considered, whether it reduced overall costs and whether it improved patient outcome. In addition, the research: (1) explored the 'diagnostic accuracy' of initial clinical investigation of the knee by an orthopaedic trainee, consultant knee specialist and consultant radiologist; (2) considered the variability and diagnostic accuracy of interpretations of knee MRI investigations between radiologists; (3) measured the strength of preference for the potential diagnostic/therapeutic impact of knee MRI (i.e. the avoidance of surgery). METHODS - RANDOMISED CONTROLLED TRIAL: The research was based on a single-centre randomised controlled trial conducted at Kent and Canterbury Hospital. Patients attending with knee problems in whom surgery was being considered were recruited from routine orthopaedic clinics. Most patients had been referred by their general practitioner. Patients were randomised to either investigation using an MRI scan (MRI trial arm) or investigation using arthroscopy (no-MRI trial arm). The study investigated the benefits of knee MRI at two levels: diagnostic/therapeutic impact (i.e. avoidance of surgery) and patient outcome (using the Short Form with 36 items and EQ-5D quality-of-life measurement instruments). Quality of life was assessed at baseline and at 6 and 12 months. Costs were assessed from the perspectives of the NHS and patients. All analyses were by intention to treat. METHODS - SUBSTUDIES (INVESTIGATION OF DIAGNOSTIC ACCURACY): For the investigation of diagnostic accuracy of initial clinical investigation, the sample comprised 114 patients recruited in a separate study conducted at St Thomas' Hospital. The sample was drawn from patients presenting at the Accident and Emergency Department with an acute knee injury. All study patients received an MRI scan, but initial diagnosis was made without access to the scan or the radiologist's report. After 12 months, all clinical notes and MRI scans of study patients were reviewed and a final 'reference standard' diagnosis for each patient was reached. Comparison was made between the diagnosis recorded by each clinician (i.e. orthopaedic trainee, knee specialist and consultant radiologist) and the reference diagnosis. METHODS - SUBSTUDIES (INVESTIGATION OF THE GENERALISABILITY OF RESULTS): For this substudy, the MRI images from 80 patients (recruited at St Thomas' Hospital) were interpreted independently by seven consultant radiologists at DGHs and the St Thomas' Hospital MRI radiologist. For each area of the knee, the level of agreement (measured using weighted kappa) between the responses of the eight radiologists and the reference standard diagnosis was assessed. METHODS - SUBSTUDIES (INVESTIGATION OF PREFERENCES): The investigation of potential patient preferences for the diagnostic/therapeutic impact of MRI was explored using a discrete choice conjoint measurement research design. Choices involved selecting between two alternative scenarios described using four attributes, and data were collected from 585 undergraduate sports science students and analysed using a random-effects probit model. RESULTS - RANDOMISED CONTROLLED TRIAL: The trial recruited 118 patients (59 randomly allocated to each arm). The two groups were similar in important respects at baseline. The central finding was of no statistically significant differences between groups in all measures of health outcome, although a trend in favour of the no-MRI group was observed. However, the use of MRI was found to be associated with a positive diagnostic/therapeutic impact: a significantly smaller proportion of patients in the MRI group underwent surgery (MRI = 0.41, no-MRI = 0.71; p = 0.001). There was a similar mean overall NHS cost for both groups. RESULTS - SUBSTUDIES (INVESTIGATION OF DIAGNOSTIC ACCURACY): The exploration of diagnostic accuracy found that, when compared to orthopaedic trainees (44% correct diagnoses) or to radiologists reporting an MRI scan (68% correct diagnoses), the accuracy rate was higher for knee specialists (72% correct diagnoses). RESULTS - SUBSTUDIES (INVESTIGATION OF THE GENERALISABILITY OF RESULTS): This generalisability study indicated that, in general terms, radiologists in DGHs provide accurate interpretations of knee MRI images that are similar to a radiologist at a specialist centre. The one area of the knee for which this did not hold was the lateral collateral ligament. RESULTS - SUBSTUDIES (INVESTIGATION OF PREFERENCES): The central finding for this substudy was that, on average and within the range specified, choices in this group of potential patients were not significantly influenced by variation in the chance of avoiding surgery. CONCLUSIONS - IMPLICATIONS FOR HEALTHCARE: The evidence presented in this report supports the conclusions that the use of MRI in patients presenting at DGHs with chronic knee problems in whom arthroscopy was being considered did not increase NHS costs overall, was not associated with significantly worse outcomes and avoided surgery in a significant proportion of patients. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH (IN PRIORITY ORDER): (1) The trial data demonstrated that the use of MRI in patients with chronic knee problems reduced the need for surgery. However, the link between diagnostic processes and changes in health outcome is indirect and the finding of no-MRI-related effect on health outcome may, therefore, be a consequence of the limited power of the trial. Further research to confirm (or contradict) these findings would be valuable. (2) The investigation of diagnostic accuracy involved comparison with a reference diagnosis established by a panel of two clinical members of the research team. It would be interesting to explore the extent to which the results would differ using an external panel. (3) The result from the preference study, indicating that the potential diagnostic/therapeutic impact of knee MRI was not highly valued, is a surprising finding that would be important to explore in general public or patient populations. (4) The focus for the trial-based aspects of this research was the DGH and patients presenting with chronic knee problems who were being considered for surgery. Care should be taken in generalising from these results to other patient groups (e.g. acute knee injuries) or to other settings (e.g. specialist centres). Further clinical trials would be required in order to answer such questions.

Partridge osteosynthesis: a prospective clinical study on the use of nylon cerclage bands and plates in the treatment of periprosthetic femoral shaft fractures.

OBJECTIVE: To evaluate the clinical use of the Partridge osteosynthesis in periprosthetic femoral fractures. DESIGN AND SETTING: Prospective nonrandomized clinical study. PATIENTS: Over a ten-year period, 222 patients presenting with femoral fractures near the tip of a hip prosthesis were treated with the Partridge system, which employs elevated cerclage nylon bands and flexible elevated nylon plates. Sixty-five fractures were located cranial to the tip of the prosthesis (Whittaker Type I), 116 at the tip (type II), and forty-one distal to the tip of the prosthesis (Type III). The population consisted of 172 female and fifty male patients, with a mean age of 79.5 years. The mean duration between the index procedure and occurrence of the second fracture was 1.5 years. In 78 percent of the patients (173 out of 222), surgery was undertaken within forty-eight hours. Fracture reduction was open, and two nylon plates set at right angles to each other were secured to the femur with six to eight nylon bands. The mean operating time was fifty-five minutes, with an average blood loss of 550 milliliters. RESULTS: There were minor wound healing problems in eighteen patients (12.6 percent); there were no deep wound infections. Thirty-three elderly patients died within the first month from medical complications. Of the 189 remaining patients, 60 percent regained their prefracture functional level within six months postoperatively, whereas 25 percent required a higher level of care. The mean time of the in-hospital stay was thirty-three days. Ninety-three percent of the fractures consolidated with abundant callus during the follow-up period of one year. CONCLUSION: The indication for the use of this simple osteosynthesis method is swift convalescence by splinting the periprosthetic femoral fractures. Even with a loose prosthesis, the fracture often healed with abundant callus and the patient could be mobilized.

Measurement of coronal plane patellar mobility in normal subjects.

This study evaluated an instrument for measuring patellar mobility in the coronal plane in normal subjects, established baseline quantitative data and compared with methods of measurement described in the literature. This data can be used as a baseline for clinical assessment of patellar mobility. The findings suggest that 8-20 mm displacement is normal patellar mobility in the coronal plane. Displacement less than 8 mm may be considered as retinacular tightness and displacement greater than 20 mm considered as abnormal retinacular laxity.

Hyaluronan forms specific stable tertiary structures in aqueous solution: a 13C NMR study.

13C NMR spectra of aqueous solutions of hyaluronan (HA) of high molecular mass, before and after digestion with testicular hyaluronidase, and of hyaluronan methyl ester were obtained at 125.8 MHz. Carbonyl peaks were assigned by using selective decoupling techniques. Spectra of digested and undigested HA showed sharp signals, except for that assigned to the acetamido carbonyl carbon in the high polymer, which was much broadened. The decreased mobility of this C==O, thus demonstrated, was caused by restricted rotation. As part of the rigid CO---NH unit, rotation of NH was therefore similarly restricted, probably because of an intermolecular H bond from NH to carboxylate groups on neighbouring HA molecules. This bond was confirmed by comparing esterified HA with unmodified HA. Methyl esterification of carboxylates was accompanied by changes in acetamido C==O resonances consistent with increased mobility of CO---NH groups. Ester C==O resonances were sharp, proving that they did not participate in sterically restricted structures such as the proposed H bonds involving unesterified carboxylate groups. C==O resonances report on the environments and on the interrelationships of amide and carboxylate groups. A detailed structure suggested for high-molecular-mass HA in aqueous solution takes account of NMR and x-ray fiber diffraction data. Antiparallel HA chains overlap in meshworks stabilized by specific H bonds and hydrophobic bonds. This highly cooperative structure, formally equivalent to beta-sheets seen in proteins, is not stable in low-molecular-mass HA solution. The results relate to structures proposed for shape modules in extracellular matrix involving chondroitin and keratan sulfates, which resemble HA in their stereochemistry.

In vivo corrosion of 316L stainless-steel hip implants: morphology and elemental compositions of corrosion products.

Eleven surgically retrieved stainless steel implants showing varying degrees of surface corrosion were examined to characterize the morphology and composition of corrosion products. The implants were fabricated to the specification AISI316L (Muller) and BS 3531 pt 1 1971-78 (Charnley). They had been in place for 9-21 y (Mean :13 y) and failures were due to aseptic loosening. The morphology and chemical compositions of corrosion products were recorded using scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDX). Nine implants had areas of corrosion covering 1-5 cm of the stem, partially or all round. Corrosion existed in layers. The layers consisted either of chromium in association with sulfur, or iron in association with phosphorus. Variable amounts of calcium and chlorine were also present in all layers. Nickel, which makes up 13% of the alloy, was persistently absent. The presence and extent of corrosion was independent of the alloy composition and could not be related to the duration of implantation.

Late functional deterioration following paralytic poliomyelitis.

Many patients with previous poliomyelitis develop 'post-polio syndrome' (PPS) in which late functional deterioration follows a period of relative stability. The frequency with which PPS can be attributed to clearly defined causes remains uncertain. We reviewed 283 newly-referred patients with previous poliomyelitis seen consecutively over a 4-year period; 239 patients developed symptoms of functional deterioration at a mean of 35 (5-65) years after the paralytic illness. Functional deterioration was associated with orthopaedic disorders in 170 cases, neurological disorders in 35, respiratory disorders in 19 and other disorders in 15. Progressive post-polio muscular atrophy was not observed. Functional deterioration following paralytic polio-myelitis is common, and associated with orthopaedic, neurological, respiratory and general medical factors which are potentially treatable.

The radiological anatomy of the scaphoid. Part 2: Radiology.

The complex shape of the scaphoid and its orientation within the carpus makes the radiological interpretation of scaphoid anatomy difficult. To improve our understanding of how the anatomy appears on plain X-ray, a study was performed using dry cadaver bones. Salient anatomical features were outlined using radiopaque markers, the bones set in wax blocks and the blocks X-rayed in the same axis as six "standard" scaphoid views. The pictures obtained were then compared with clinical X-rays.

Education and training opportunities in trauma and orthopaedics in SE Thames Region.

In preparation for the introduction of the specialist registrar grade the specialist advisory committee (SAC) in orthopaedics developed a six-year structured training programme leading to the award of the Certificate of Completion of Specialist Training (CCST). A team comprising the regional adviser in orthopaedics, the two regional programme directors and an associate dean of postgraduate medicine visited all the departments of orthopaedics in the South East Thames Region in order to evaluate the training opportunities they provided. This paper describes the methodology used during these visits, the lessons learned and the conclusions drawn.