Women in trauma and orthopaedics: are we losing them at the first hurdle?

INTRODUCTION

Diversity in the healthcare workforce is associated with improved performance and patient-reported outcomes. Gender disparity in Trauma and Orthopaedics (T&O) is well recognised. The aim of this study was to compare factors that influence career choice in T&O between male and female final-year students. Furthermore, the trend of representation of women in T&O over the last decade was also compared with other surgical specialities.

METHODS

An online survey of final-year students who attended nationally advertised T&O courses over a 2-year period was conducted. Data from NHS digital was obtained to assess gender diversity in T&O compared with other surgical specialities.

RESULTS

A total of 414 students from 13 UK medical schools completed the questionnaire. Compared with male students (34.2%), a significantly higher proportion of women (65.8%) decided against a career in T&O, p<0.001. Factors that dissuaded a significantly higher percentage of women included gender bias, technical aspects of surgery, unsociable hours, on-call commitments, inadequate undergraduate training and interest in another specialty (p<0.05). Motivating factors for choosing a career in T&O were similar between both sexes. T&O was the surgical specialty with the lowest proportion of women at both consultant and trainee level over the last decade.

CONCLUSION

T&O remains an unpopular career choice among women. To enhance recruitment of women in T&O, future strategies should be directed toward medical students. Universities, orthopaedic departments and societies must work collaboratively to embed culture change, improve the delivery of the undergraduate curriculum, and facilitate students' exposure to operating theatres and female role models.

Functional results and complications following conversion of hip fusion to total hip replacement

Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in three hips. Mean follow up was five years (two to 15). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in seven (39%) hips, in one case resulting in joint ankylosis. No hips dislocated.

Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function.

Fixation of intracapsular fractures of the femoral neck in young patients

The aim of this study was to determine the comorbid risk factors for failure in young patients who undergo fixation of a displaced fracture of the femoral neck. We identified from a prospective database all such patients ≤ 60 years of age treated with reduction and internal fixation. The main outcome measures were union, failure of fixation, nonunion and the development of avascular necrosis.

There were 122 patients in the study. Union occurred in 83 patients (68%) at a mean follow-up of 58 months (18 to 155). Complications occurred in 39 patients (32%) at a mean of 11 months (0.5 to 39). The rate of nonunion was 7.4% (n = 9) and of avascular necrosis was 11.5% (n = 14). Failures were more common in patients over 40 years of age (p = 0.03). Univariate analysis identified that delay in time to fixation (> 24 hours), alcohol excess and pre-existing renal, liver or respiratory disease were all predictive of failure (all p < 0.05). Of these, alcohol excess, renal disease and respiratory disease were most predictive of failure on multivariate analysis.

Younger patients with fractures of the femoral neck should be carefully evaluated for comorbidities that increase the risk of failure after reduction and fixation. In patients with a history of alcohol abuse, renal or respiratory disease, arthroplasty should be considered as an alternative treatment.

Early syphilis: a cause of mono-arthritis of the knee

The number of syphilis cases has increased in the UK in recent years, but many clinicians have limited experience in the diagnosis and treatment of this disease. If early diagnosis is not made and treated promptly with antibiotics, the disease may remain latent until the more serious manifestations of tertiary syphilis develop. We present the case of a 27-year-old man who presented with an acute mono-arthritis secondary to syphilis. The condition responded to antibiotic therapy. Orthopaedic surgeons should be aware of the diagnosis and consider it in patients with an acute arthropathy.

Fractures of the tibial spine: epidemiology and outcome

We documented functional outcome in 83 knees with tibial spine fractures. The mean age at injury was 35 years. There was a medial collateral ligament sprain in 17 knees and posterolateral corner injury in three knees. Twenty patients with displaced tibial spine fractures were treated with fixation of the tibial spine and 63 patients with undisplaced or minimally displaced fractures were treated non-operatively. Fourteen (22%) non-operatively treated knees developed symptomatic instability, three of which underwent ACL reconstruction. Tibial spine fixation restored stability in 18 of 20 knees, but knee stiffness was more common in this group when compared to non-operatively treated knees (60% vs 19%, p<0.0005). Patients with postoperative knee stiffness had a mean age of 28 years compared to 18 in patients with no knee stiffness (p<0.05). We concluded that tibial spine fracture in skeletally mature patients is associated with a significant risk of knee stiffness and instability.

Intramedullary nailing of fractures of the tibia in diabetics

We reviewed 27 diabetic patients who sustained a tibial fracture treated with a reamed intramedullary nail and compared them with a control group who did not have diabetes. There were 23 closed fractures and four were open. Union was delayed until after six months in 12 of the 23 (52%) diabetic patients with closed fractures and ten of the 23 (43%) control patients (p = 0.768). In two patients with diabetes (9%), closed tibial fractures failed to unite and required exchange nailing, whereas all closed fractures in the control group healed without further surgery (p = 0.489). In both the diabetic and control groups with closed fractures two patients (9%) developed superficial infections. There were two (9%) deep infections in diabetic patients with closed fractures, but none in the control group (p = 0.489).

Overall, there was no significant difference in the rate of complications between the diabetic patients and the control group, but there was a tendency for more severe infections in patients with diabetes.

Natural history of fixed flexion deformity following total knee replacement: a prospective five-year study

We investigated fixed flexion deformity (FFD) after total knee replacement (TKR). Data relating to 369 cruciate-retaining unilateral TKRs performed at a single institution were collected prospectively. Fixed flexion was measured pre-operatively and at one week, six months, 18 months, three years and five years after surgery. Using binary logistic regression, pre-operative FFD was a predictor of post-operative FFD > 10 degrees at one week (p = 0.006) and six months (p = 0.003) following surgery. Gender was a predictor at one week (p = 0.0073) with 24% of women showing a FFD > 10 degrees compared with 37% of men. We have shown that a gradual improvement in knee extension can be expected up to three years after surgery in knees with FFD. By this time residual FFD is mild or absent in the majority of patients, including those who had a severe pre-operative FFD.

Weight change following total hip replacement: A comparison of obese and non-obese patients

BACKGROUND

Weight loss is desirable in obese patients prior to hip replacement but poor mobility secondary to hip dysfunction may limit attempts at weight reduction because of reduced exercise tolerance.

METHODS

We followed 140 patients prospectively to investigate weight change and functional outcome in obese and non-obese patients following total hip arthroplasty. Weight and the Harris hip score was measured one week prior to surgery and three years post-operatively.

RESULTS

Fifty nine patients were obese (BMI > or = 30). The mean weight of obese patients increased from 88 kg pre-operatively to 92 kg following surgery (p<0.001). In non-obese patients pre-operative weight was 69 kg and post-operative weight 70 kg (p=0.106). In the obese group 75% of patients gained a mean of 6.77 kg (p<0.001) and 19% of patients lost a mean of 4.8 kg (p<0.01). In the non-obese group, 60% of patients gained a mean of 4.2 kg (p<0.001) and 31% of patients lost an average of 4.7 kg (p<0.001). The mean Harris hip score was 90 in non-obese patients and 85 in obese patients three years post-operatively (p<0.01).

CONCLUSION

Weight increase is common following total hip replacement despite improved function but the magnitude of weight increase appears to be greater in patients who are obese. Obesity was also associated with lower functional hip scores but the differences were small and unlikely to be of clinical significance.

Pre-operative predictors of the requirement for blood transfusion following total hip replacement

We have reviewed prospective data on 1016 patients who underwent unilateral total hip replacement to establish the pre-operative risk factors associated with peri-operative blood transfusion. Most patients who required transfusion were older and were of lower weight, height, pre-operative haemoglobin level and body mass index than patients who were not transfused. Multivariate analysis revealed that only the pre-operative haemoglobin level and the patients weight were identified as significant independent factors increasing the need for transfusion (p < 0.001). A haemoglobin level below 12 g/dl was associated with a threefold increase in transfusion requirement.