Background

Surgical patients have cost the NHS 1.3 billion GBP from 1995. Spinal pathologies can present diagnostic challenges, and the consequences of delayed diagnosis or surgical complications can be devastating and so creating high indemnity costs.

We aim to highlight the spinal associated litigation patterns within the United Kingdom.

Introduction: Hip fractures guidelines suggest that ‘all patients with fracture neck of femur should be operated upon as soon as possible (within 24hrs). Despite this different studies suggest that still 11% of hip fractures are treated conservatively (varies 3–37%).

Aim: Our main aim was to find out whether there is a place for non-operative treatment as a definitive primary option in patients with significant medical comorbidity. We also wanted to audit best practice for conservative treatment in medically compromised patients and in those patients whose hip fractures are not suitable for surgical repair.

Methods: We did this audit in 2007 collating information on 1010 hip fracture patients across 14 NHS hospitals in England. 50 out of 1010 (4.95%) patients were treated conservatively. We reviewed the records of these 50 patients (range 66–99, mean age 78 years) and looked at patient demographics, radiographic features, mobility, accommodation, cognition, and ASA class were recorded.

Results: There were 17 males and 33 females patients managed conservatively in our study. Before injury, 37 (74%) were living at home and 13 (26%) were institutionalised. During hospitalisation, 4 became bedridden and 30 died (mainly due to medical comorbidities). Among these 50 patients, eight were deemed physically unfit for surgery by anaesthetists and two by medical consultants. The decision of conservative treatment was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. Five patients refused surgery and five patients were palliative due to terminal illnesses. Patients who did not proceed to surgery (either treated conservatively by choice or presented at admission with complications) had significantly higher mortality rates (overall mortality rate 60 %) suggesting that they were physiologically much worse group of patients.

Discussion: As the average life span of our population increases, some hip fractures are now treated non-operatively because of the possibility of severe or fatal complications due to surgery. Often, refusal of surgery by the patient or the patients’ family obligates the need for non-operative treatment. It is acceptable to postpone the surgery if the patients are medically unfit for these reasons (eg. acute cardiac event, patient dying, severe aortic stenosis, multi-organ failure). It is not considered appropriate if surgery is cancelled due to pyrexia, chest infection, borderline Hb or awaiting ECHO for murmur. Administrative or logistic reasons (eg. no HDU bed) needs to be looked at higher levels as well.

Aim: Our aim was to find the effect of implementation of European working time directive on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: The audit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of the this and have identified a potential area of concern.

Results: An orthopaedic trainee of registrar level(Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non-training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There is a definite trend suggesting decrease in number of operations by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP.

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England.

Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant.