We summarise findings from surveys of graduates from UK medical schools over 31 years. Serial surveys have been undertaken in 1974, 1977, 1980, 1983, 1993, 1996, 1999, 2000 and 2002. Questionnaires were sent to 33,151 doctors; 24,621 (74.3%) replied. Three years after qualification, 70.8% replied to a second survey; 5-years after qualification, seven cohorts were re-surveyed.

Trauma and orthopaedic surgery was the first choice career for 5.0% (men) and 1.0% (women) 1 year after qualification, and 5.2% (men) and 0.8% (women) at 5 years. Of those with T&O as first choice, 35% who chose it in year one, 56% in year three, and 84% in year five were working in it eventually. Experience as a student or junior, self-appraisal of skills, a particular teacher and enthusiasm for the specialty were the most important influences.

There has been an increase in the percentage of women choosing surgical careers. However, the much higher percentage of men who choose T&O surgery remains striking. The specialty needs to consider whether this matters. Women currently comprise about 60% of the medical school intake in the UK.

This study shows that doctors who ultimately pursued a surgical career made that choice by year 3 (equivalent to ST1) and between 84-92% had settled on the specialty by year 5 (ST3). Career progression for this historical cohort did not require an early commitment and a greater decisiveness may be anticipated in the more expectant system of Modernising Medical Careers.

It is unknown whether recent working time directives will influence career choice. This study defines T&O doctors to be highly motivated by work and not influenced by long working hours or competing domestic demands. This low priority places the specialty at the bottom of comparative tables. A change in work-life balance may directly impact future specialty recruitment.

Purpose of the study: Hemophilic arthropathy is often located in the knee joint. Total knee arthroplasty (TKA) is the ultimate solution to total joint destruction, often observed in young patients. The purpose of this study was to evaluate the outcome of TKA in hemophilic patients and to describe specific features.

Material and methods: Hemophilics who underwent TKA between 1990 and 2004 were reviewed at mean 4.7 years follow-up: 30 TKA (7 posterior stabilized, 23 with preservation of the posterior cruciate) were implanted in 21 men, mean age 39 years, 17 with hemophilia A et 4 with hemophilia B. Seventeen patients were HBV-positive and eight were HIV-positive. Coagulation factors substitution was managed by the regional center for the treatment of hemophiliacs starting the day before the operation and for a minimal postoperative period of 21 days. The Knee Society score was used for assessment of clinical outcome.

Results: Preoperatively, mean flexion was 75° (range 40–100°), mean permanent flexion was 20° (range 5–45°). Range of joint motion was 56° on average (range of range of motion 10–105°). Early postoperative hemarthrosis occurred in eleven knees and seven of these required revision from day 4 to day 15. The four others resolved spontaneously. Six late infections (20%) developed in five patients (one bilateral infection). One patient was treated by arthroscopic wash-out, and four by arthrotomy. One required revision TKA in a two-stage procedure. Five patients received an adapted antibiotic therapy for an identified germ; the germ could not be identified in one patient. At last follow-up, mean flexion was 85°, mean permanent flexion was 10°, and mean range of motion was 71°. None of the patients complained of pain both at rest and during exercise.

Discussion: Hemophilic arthropathy is particularly painful, producing stiff joints in these immunodepressed patients. The known high rate of complications was again observed in this series, particularly infectious complications after TKA in hemophiliacs. These complications did not however alter the functional outcome. The gain in joint motion was modest but the absence of pain was a satisfactory result for these patients.