Title : The impact of the 2023 ST3 national selection criteria change on SHO operative exposure and training culture in Neck of Femur (NOF) fracture surgery
Abstract:
Background: Selection criteria for ST3 (registrar-level) national recruitment in Trauma & Orthopaedics changed in November 2023 for the registrars to start in August 2024 from including Extracapsular neck of femur fracture to all neck of femur fractures, both intra capsular and extra capsular. Anecdotally, this shift has increased pressure on Senior House Officers (SHOs) to accumulate hands-on operative experience earlier in training, particularly in Neck of Femur (NOF) fracture surgery. This service evaluation examines whether SHO operative involvement in NOF fracture procedures changed following this policy shift.
Methods:Two years of operative notes for NOF fracture operations were retrospectively reviewed ,one year pre change and from October 2023 to October 2022 and post change from November 2025 to November 2024. For each operation type — hemiarthroplasty (intracapsular, IC), cannulated hip screws (CHS, IC), dynamic hip screw (DHS, extracapsular, EC) and intramedullary (IM) nail (EC) — three outcomes were compared between periods: (1) the proportion of cases where an SHO was primary surgeon, (2) the proportion of cases where an SHO scrubbed in, and (3) the conditional probability of an SHO performing the operation given that they had scrubbed in. Chi-square tests were used for 2x2 comparisons with expected cell counts ≥5; Fisher's exact test was used otherwise.
Results: Across all NOF operations combined (n=960), the proportion of cases where an SHO was primary surgeon rose from 13.6% pre-change to 23.5% post-change (p<0.001), and the proportion of cases where an SHO scrubbed in nearly doubled, from 32.0% to 54.3% (p<0.001). However, the conditional probability of performing the operation given the SHO was already scrubbed in was unchanged (42.7% vs 42.8%, p=1.00). This pattern held for hemiarthroplasty and DHS individually: both showed significant increases in SHO performance and scrubbing-in rates, but no change in conversion rate once scrubbed in. IM nail showed no significant change in any measure. CHS was the exception: both scrubbing-in and conditional performance rates rose significantly (25.0%→51.0% and 25.0%→80.0% respectively), though based on small case numbers.
Conclusion: Following the November 2023 change to ST3 selection criteria, SHOs are scrubbing into NOF fracture operations substantially more often, and this increased presence — rather than any change in supervisors' willingness to hand over the procedure once an SHO is already scrubbed in — appears to be the principal driver of increased SHO operative rates for hemiarthroplasty and DHS. IM nailing has not been affected. CHS shows a different pattern, with more scrubbed-in SHOs also being allowed to perform the procedure, though this finding is based on small numbers and warrants further data collection.
