Since 2003 Trauma and Orthopaedic trainees in the UK and Ireland have routinely submitted data recording their operative experience electronically via the eLog-book. This provides evidence of operative experience of individuals and national comparisons of trainee, trainer, hospital and training programme performance. We have analysed trauma surgery data and established standards for training.

By January 2008 there were over 4 million operations logged. Operations performed and uploaded since 2003 have been included. Each trainee’s work is analysed by ‘year-in-training’. Data on levels of supervision, missed opportunities (where the trainee assisted rather than performed the operation) was analysed. The average number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT one (=ST3) to six (=ST8) respectively. There were only 22% of missed opportunities throughout six years of training. A high level of experience is gained in hip fracture surgery (121 operations) and forearm (30), wrist (74) and ankle (47) operative stabilisation over the six years. However, the average number of tibial intra-medullary nails (13), external fixator applications (12) and childrens’ elbow supracondylar fracture procedures (4) performed is low. We are also able to identify trainees performing fewer operations than required during their training (two standard deviations or more below the mean for their YIT). We expect a trainee to have performed at least 255, 383, 473, and 531 trauma operations at the end of YIT three to six respectively.

The eLogbook is a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. This analysis has established a baseline which can be used to identify trainees who are falling below the required operative experience.

An online survey has been carried out to evaluate the compliance with the OCAP learning tools, and the availability of clinical experience to early years’ trainees in Trauma and Orthopaedics in 2007–8. Three surveys were planned over the year, and we present the results from the first two surveys. Over the initial eight month period, 335 trainees in Trauma and Orthopaedic posts responded. There was considerable variation in the proportion of responses from different deaneries, and it was felt this reflected differences in the use of the two logbooks available (FHI or ISCP).

Respondents were FTSTAs (50%), ST1s (11%) and ST2s (29%). The respondents reported their operative experience was poor with low numbers of index procedures – the median values being 2 DHS, 1 Hemiarthroplasty and 0 for Ankle ORIFs performed as the lead surgeon in the first 4 months, rising to 3, 1 and 1 respectively in the second. As an assistant the numbers were 3, 4 and 3. FTSTAs had done more procedures as lead surgeon. It is not clear whether this reflects motivation, or whether they are trainees who were unable to secure training posts due to seniority and were already more experienced. Many posts were entirely ward based.

Improvements in meetings with Assigned Educational Supervisors were noted, as was the use of the learning agreements, and with registration rates with the ISCP. There was considerable variation between posts, hospitals and deaneries, and a tool was developed to summarise this data to be post-, trainee-, and duration-specific. Summaries of each post were distributed to Training Program Directors, Heads of School, and the SAC. Although some improvement has occurred, further rounds of the survey are necessary to ensure that this continues. The next round will commence in September 2008 to complete twelve months of data.

Relatively high rates of fracture of the femoral stem of total hip replacements were seen with early designs manufactured with stainless steel. Improvements in metallurgy, alloy chemistry, materials and stem design have led to a reduction in the incidence of this complication and the occurrence of fracture with modern femoral stems is a now a rare event. However, the implantation of modern stems into heavy patients and the use of higher offset stems leads to considerable testing of the mechanical capabilities of some stem designs.

We present ten cases of fracture of modern stainless steel polished tapered stems. The fractures occur either in the neck, or in the distal half of the stem. Our clinical data suggests that heavy patients with small stems and high offsets are at risk of breaking their implants. Varus positioning of the stem in a number of cases further increases the bending moment of the stems, and the sacrifice of cement mantle thickness for implant size within narrow medullary canals may lead to the loss of proximal support. Failure analysis of the retrieved high nitrogen stainless stems also suggests there may be metallurgical factors that contribute to their failure.

On the basis of our findings, careful consideration is required when using high offset stainless steel stems in large patients.

Pain in the distribution of the sciatic nerve is common in the elderly. In the presence of a long-standing joint replacement, consideration should be given as to whether compression might be due to an extraspinal cause. We present three women, in whom a mass of wear debris from a previous total hip replacement caused compression of the sciatic nerve posterior to the hip. The symptoms were relieved immediately following operation.

Fifty-two children with 62 discoid lateral menisci were reviewed at an average follow-up of 5.5 years. Their average age at operation was 10.5 years and the mean delay in diagnosis was 24 months. Most of the children had vague and intermittent symptoms and the classical clunk was demonstrable in only 39% of the knees. An associated osteochondritis dissecans of the lateral femoral condyle was seen in seven knees. Forty-eight knees with symptomatic torn discoid menisci underwent open total lateral meniscectomy, six had arthroscopic partial meniscectomy and eight knees with intact discoid menisci, were left alone. Based on Ikeuchi's grading (Ikeuchi 1982), 37% of the knees had an excellent result, 47% had a good result and 16% had a fair result: none was poor. Arthroscopic partial meniscectomy is recommended only when the posterior attachment of the discoid meniscus is stable. A total meniscectomy is indicated for the Wrisberg-ligament type of discoid meniscus with posterior instability.

Four hundred and fifteen patients with cementless acetabular components of either a smooth threaded (130) or porous surfaced (285) variety were compared for clinical symptoms and radiographic signs of component loosening. At a mean 4.8 year follow-up none of the patients with porous acetabular components had signs of component instability. At a mean 3.9 year follow-up 27 (21%) of the patients with a smooth threaded acetabular component showed radiographic signs of instability and 33 (25%) had clinical symptoms. The disappointing short-term results with these threaded cups in our hands have prompted us to abandon their use in favour of the porous surfaced hemispherical cups.