Overall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.
Background
Plastic surgery training in the UK continues to evolve towards an outcome-based rather than time-served curriculum. UK plastic surgery trainees are appointed nationally, and are assessed according to national standards, but training is delivered regionally. This study sought opinion from current UK plastic surgery trainees in order to highlight strengths and shortcomings of the higher surgical training programme.
Method
A cross-sectional study was designed and administered by the UK Plastic Surgery Trainees Association (PLASTA). A questionnaire was distributed to all UK plastic surgery trainees holding a National Training Number, using the REDCap web-based application.
Results
Of the 320 UK plastic surgery trainees, 131 (41%) participated in this survey, with responses from all 12 UK training regions. The most common subspecialty career aspirations for trainees were hand surgery, cleft lip and palate, lower limb and oncoplastic breast reconstruction. The survey highlighted regional variation in teaching programmes, the ability to achieve indicative operative logbook numbers, and training in aesthetic surgery. Of the trainees, 82% expressed a desire to undertake a fellowship within their training, but most did not know whether their deanery would support this. Fifteen per cent of the respondents were currently training flexibly and the majority of these had experienced negative behaviours towards their less than full time working status. Of the respondents, 44% reported stress, 25% reported a lack of autonomy and 17% reported feeling burnt out at work at least once a week. A total of 85% perceived that they did not have access to a mentoring service.
Conclusions
Plastic surgery remains a popular and highly competitive surgical speciality in the UK, and many trainees reported high levels of satisfaction during their training. Aspects of training that could be improved have been highlighted and recommendations made accordingly.
Introduction Severe open tibial fractures are limb-threatening injuries. Outcomes depend on a complex interplay of patient, injury and treatment factors. 2009 guidelines from the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommend prophylactic intravenous antibiotic administration within three hours of injury. More recent National Institute for Health and Care Excellence (NICE) 2016 guidelines recommend pre-hospital antibiotic administration where possible. This study aimed to analyse the impact of time to antibiotics on development of deep infection. Methods Adult acute Gustilo-Anderson 3B open tibial fractures managed at a single UK Major Trauma Centre were reviewed retrospectively over a three-year period, including a period before and after the regional ambulance service introduced a policy of administering prehospital intravenous antibiotics to open fractures in 2016. Development of deep infection was recorded as the primary outcome measure. Complete case regression analysis was performed. Time was assessed as a continuous variable and as thresholds with antibiotics received within one or three hours of injury. Results 156 patients with 159 fractures were included. Following introduction of new guidance in 2016, median time to antibiotics decreased from 180 to 160 minutes and more patients received pre-hospital antibiotics (2% vs. 33%). Overall, 7.5% developed deep infection (n=12) within a median follow-up of 26 months. Logistic regression found no relationship between any independent variable, including time to antibiotic administration, and development of deep infection. Conclusions There are a variety of factors identified in the literature and in national policies and treatment guidelines as potentially modifiable to reduce the risk of deep infection following open fractures. In this study, time to antibiotic administration was not associated with the risk of developing deep infection. The results of this study demonstrate a low infection rate, which may be due to expedient expert care delivered by a dedicated orthoplastic service in line with national guidance where achievable.
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