Orthopaedic surgery

An artificial hip joint being inserted

Each of these subspecialties is also characterised by slightly different working patterns. The proportion of time spent in clinics and in theatre varies depending on the subspecialty chosen. In general terms, time is divided roughly equally between the operating theatre and the outpatients department. In addition, the management of inpatients is always important.

Trauma surgery

All orthopaedic surgeons do trauma surgery, including injuries affecting the limbs and spine (bony or otherwise). Many injuries do not occur between 9 am and 5 pm, and so, as a trainee, many late nights are spent admitting and stabilising trauma patients. Although perhaps the most demanding, these patients are also often the most rewarding as they frequently return to full function.

Lower limb surgery

Increasingly, this subspecialty is being further divided into hip, knee, and foot and ankle surgery. Hip surgery includes joint replacement and revision surgery. Surgery of the knee includes replacements, arthroscopic surgery, and ligament reconstructions. The foot and ankle surgeon operates predominantly on the ankle and below; ankle replacements and the correction of congenital or acquired deformities are included.

Upper limb surgery

Shoulder and elbow surgery is a rapidly developing field. It can be paralleled to surgery in the lower limb. Shoulder and elbow replacement surgery are both becoming more widespread. The highly mobile nature of the joints concerned confers particular challenges.

Hand surgery

Hand surgery and upper limb surgery overlap considerably. Hand surgery is the specialty that concentrates on restoring both form and function to the hand. It does not just include bony procedures such as joint replacements and fusions, but includes many soft tissue procedures from tendon transfer procedures to brachial plexus repairs.

Spinal surgery

This is one of the most technically challenging branches of orthopaedic surgery. It deals exclusively with traumatic, degenerative, and congenital disorders of the spine.

Oncological surgery

This highly specialised branch of orthopaedics is limited to a few tertiary referral centres around the United Kingdom. It includes limb salvage and reconstructive procedures following complex cancer surgery, as well as the primary cancer surgery itself.

Basic surgical rotation

Once you have decided that a career in surgery (orthopaedic or otherwise) is for you, the next step is to gain a place on a basic surgical rotation. Most rotations provide a comprehensive teaching programme covering many of the topics on the syllabus of the Royal College of Surgeons. They have the added attraction that you are able to remain in one area for up to three and a half years. They are popular and therefore competitive. Requirements for basic surgical rotations can be found at the website for the Royal College of Surgeons (www.rcseng.ac.uk).

Member of the Royal Colleges of Surgeons

An inevitable part of the basic surgical rotation is the exam for membership of the Royal College of Surgeons. Although perhaps less daunting than the old style fellowship exam, this is still a formidable obstacle that requires a lot of effort to overcome. Essentially, the exam consists of three parts based on the Royal College of Surgeons STEP course:

Multiple choice papers--These are the first part of the MRCS exam and can be taken at any point after entering basic surgical training.

Viva--The viva consists of three 20 minute sessions covering the entire syllabus in great depth with up to three examiners at each station. Once you have attempted this section, you have only two years to complete both the multiple choice and clinical exams successfully. If not completed within this time (with the exception of flexible trainees and certain other special cases), you are no longer eligible for further attempts. You are not even able to start again at the beginning.

Clinical exam--Candidates must have passed the other two parts and have completed at least 22 months in approved training posts before attempting this section. The exam assesses the candidate's clinical skills and knowledge in a series of short cases and objective structured clinical exams.

Once you have passed all three exams you are eligible for entrance to the college and lose that hard won Dr label on your name badge, as surgeons in the UK are called ‘Mr’ or ‘Miss’.

The next step

Once the basic surgical training has been completed and all exams passed it is time to start applying for a national training number. Competition at this level is fierce and simply completing your rotation and passing the exams is rarely enough. Rotations have a variety of criteria for shortlisting candidates on a point scoring system. Usually a minimum of 12 to 18 months in orthopaedics is required, but experience in other related specialties, such as intensive care or plastic surgery, often counts for further points.

Most rotations also require candidates to have experience in research, audit, and teaching. This is usually translated into having some publications and presentations under your belt. These are not easy to come by, however, especially as most senior house officer posts are for only six months. It is for this reason that research and senior house officer posts are in such demand.

Registrar

Registrar posts are generally one of four types:

Locum appointment for service--This is not a training post and is simply the way that long term locum posts are advertised.

Locum appointment for training--These locum posts are accredited for training and count towards the number of years spent on a registrar rotation. These used to be a guaranteed stepping stone to gain a permanent place on a rotation, but this is no longer the case.

Fixed term training appointment--Registrar posts for foreign trainees without residency rights.

Higher surgical training--The holy grail for all orthopaedic senior house officers. The registrar training rotations are six year appointments that are responsible for all your training needs (both surgical and academic). They are based in certain regions and offer a prolonged period of geographical stability in the otherwise nomadic lifestyle of a trainee.

The six year programmes offer training in most orthopaedic subspecialties. If a trainee has a particular interest in a certain field then the opportunity for further elective periods, known as fellowships, can be arranged. These fellowships are often taken abroad--for example, in the United States or Australia.

In addition to continuing your surgical training the need to carry out both research and audit remains and you will be expected to participate in both. Towards the end of the registrar training looms the FRCSOrth exam. All of the knowledge learnt for the member of the Royal College of Surgeons exam which has slowly faded, including the basic sciences, must be learnt again. Once through these obstacles a demanding, challenging, and highly rewarding career as a consultant orthopaedic surgeon beckons.

PRINCESS MARGRET ROSE ORTHOPAEDIC HOSPITAL

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