The Impact of Exposure to Previous Disasters on Hospital Disaster Surge Capacity Preparedness in Finland: Hospital disaster surge capacity preparedness.

OBJECTIVE: As disasters are rare and high-impact events, it is important that the learnings from disasters are maximized. The aim of this study was to explore the effect of exposure to a past disaster or mass casualty incident (MCI) on local hospital surge capacity planning. METHODS: The current hospital preparedness plans of hospitals receiving surgical emergency patients in Finland were collected (n = 28) and analyzed using the World Health Organization (WHO) hospital emergency checklist tool. The surge capacity score was compared between the hospitals that had been exposed to a disaster or MCI with those who had not. RESULTS: The overall median score of all key components on the WHO checklist was 76% (range 24%). The median surge capacity score was 65% (range 39%). There was no statistical difference between the surge capacity score of the hospitals with history of a disaster or MCI compared to those without (65% for both, P = 0.735). CONCLUSION: Exposure to a past disaster or MCI did not appear to be associated with an increased local hospital disaster surge capacity score. The study suggests that disaster planning should include structured post-action processes for enabling meaningful improvement after an experienced disaster or MCI.

Patient injury claims involving fractures of the distal radius.

Background and purpose - Optimal treatment for distal radius fractures remains controversial, with a significant number of fractures resulting in complications and long-term morbidity. We investigated patient injury claims related to distal radius fractures to detect the critical steps in the treatment leading to avoidable adverse events Patients and methods - We analyzed all compensated patient injury claims in Finland between 2007 and 2011. Claims were collected from the Patient Insurance Center's (PIC) nationwide claim register. Patients of all ages were included. Each claim decision, original patient records, and radiographs related to treatment were reviewed. Results - During the study period, the PIC received 584 claims regarding distal radius fractures, of which 208 (36%) were compensated. Pain and impaired wrist function were the most common subjective reasons to file claims among compensated patients. In 66/208 patients, more than 1 adverse event leading to patient injury was detected. The detected adverse events could be divided into 3 main groups: diagnostic errors (36%, n = 103), decision/planning errors (30%, n = 87), and insufficient technical execution (32%, n = 91). Issues related to malalignment were the main concerns in each group. Diagnostic errors were often related to incorrect assessment of the fracture (re)displacement (75%, n = 78). All of the decision-making errors concerned physicians' decisions to accept unsatisfactory fracture alignment. The most common technical error was insufficient reduction (29%, n = 26). Interpretation - We identified avoidable adverse events behind patient injuries related to distal radius fracture treatment. This study will help physicians to recognize the critical steps in the treatment of this common fracture and enhance patient safety.

Patient injuries in primary total hip replacement.

Background and purpose - Although the results of primary total hip replacements (THRs) are generally excellent, sometimes serious complications arise. Some of these severe complications are considered to be patient injuries. We analyzed primary THR-related patient injuries in a nationwide setting. Patients and methods - We evaluated all the primary THR-related patient injury claims in Finland between 2008 and 2010. We used the original medical records and 2 nationwide registries, the Care Register for Social Welfare and Health Care and the Patient Injury Claim Register. Results - We identified 563 claims, 44% of which were compensated (n = 250). Of these 250 compensated claims, 79% were considered to be avoidable (treatment injuries) and 21% were severe unexpected infections (with a preoperative infection risk of less than 2%). The most common type of technical error was cup malposition (31%). High-volume hospitals (with an annual primary THR volume ≥ 400) had a lower patient injury rate. In lower-volume hospitals (with an annual primary THR volume of < 400), the relative risks (RRs) of patient injury for any reason, due to technical errors, or because of cup malposition were 2-fold (95% CI: 1.6-3.1), 4-fold (95% CI: 2.3-6.2), and 9-fold (95% CI: 3-28), respectively, compared to high-volume hospitals. Interpretation - Our study provides the first comprehensive nationwide data on THR-related patient injury types. Hospital volume was associated with the quality and quantity of errors detected. An annual hospital volume of ≥ 400 primary THRs was established as a protective factor against patient injuries.

Fatal surgical or procedure-related complications: a Finnish registry-based study.

INTRODUCTION: In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. MATERIALS AND METHODS: In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. RESULTS: Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. CONCLUSION: Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

Predictors of poor outcomes following deep infection after internal fixation of ankle fractures.

The development of deep infection following operative treatment of ankle fractures can have catastrophic consequences. The aim of this study was to identify factors predisposing to treatment failure of an infected ankle fracture. Out of 1923 consecutive ankle fracture operations we identified 97 patients with deep infection necessitating at least one surgical debridement. The outcome measure was a clinical failure or success of the treatment. Various parameters considered to predict clinical outcome were evaluated. Treatment failure occurred in 27% of patients with deep infection necessitating surgical debridement. The mean age of these patients was 54 years and the mean follow-up time was 22 months. The variables that were independently associated with an increased risk of treatment failure included smoking, postoperative malreduction, hardware removal from an ununited fracture and the need for two or more additional debridements. Other significant risk factors included diabetes, alcohol abuse, high-energy injury, Danis-Weber type C fracture, multibacterial infection and ununited fracture at debridement. Our study showed that smoking, postoperative malreduction and hardware removal prior to fracture union were the most important factors predisposing to a permanent complication following an ankle fracture infection. We recommend that hardware be removed only after fracture union has been confirmed.

Risk factors for deep surgical site infection following operative treatment of ankle fractures.

BACKGROUND: Surgical site infection is one of the most common complications following ankle fracture surgery. These infections are associated with substantial morbidity and lead to increased resource utilization. Identification of risk factors is crucial for developing strategies to prevent these complications. METHODS: We performed an age and sex-matched case-control study to identify patient and surgery-related risk factors for deep surgical site infection following operative ankle fracture treatment. We identified 1923 ankle fracture operations performed in 1915 patients from 2006 through 2009. A total of 131 patients with deep infection were identified and compared with an equal number of uninfected control patients. Risk factors for infection were determined with use of conditional logistic regression analysis. RESULTS: The incidence of deep infection was 6.8%. Univariate analysis showed diabetes (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.0, 4.9), alcohol abuse (OR = 3.8, 95% CI = 1.6, 9.4), fracture-dislocation (OR = 2.0, 95% CI = 1.2, 3.5), and soft-tissue injury (a Tscherne grade of ≥1) (OR = 2.6, 95% CI = 1.3, 5.3) to be significant patient-related risk factors for infection. Surgery-related risk factors were suboptimal timing of prophylactic antibiotics (OR = 1.9, 95% CI = 1.0, 3.4), difficulties encountered during surgery, (OR = 2.1, 95% CI = 1.1, 4.0), wound complications (OR = 4.8, 95% CI = 1.6, 14.0), and fracture malreduction (OR = 3.4, 95% CI = 1.3, 9.2). Independent risk factors for infection identified by multivariable analyses were tobacco use (OR = 3.7, 95% CI = 1.6, 8.5) and a duration of surgery of more than ninety minutes (OR = 2.5, 95% CI = 1.1, 5.7). Cast application in the operating room was independently associated with a decreased infection rate (OR = 0.4, 95% CI = 0.2, 0.8). CONCLUSIONS: We identified several modifiable risk factors for deep surgical site infection following operative treatment of ankle fractures.

International benchmarking of tertiary trauma centers: productivity and throughput approach.

BACKGROUND: Care process in tertiary trauma centers consists of a chain of care phases in different departments from the emergency department (ED) to post-operative rehabilitation. The historical evolution of healthcare systems and organizations has led to variations in trauma patient processes in different countries. The present study is aimed at revealing differences in the throughput and productivity of trauma patient processes between German (UKB) and Finnish (HUS) tertiary trauma centers. Problems related to the comparison of different healthcare systems were also identified. The share of patients discharged was used as a control measure. RESULTS: The biggest differences between the hospitals were found in the use of resources in the ED and in post-operative care. Despite problems in defining comparable patients and resources, ED productivity was significantly higher in UKB. Post-operative care was, on average, 41% shorter in HUS. However, the share of patients discharged was significantly higher in UKB (96.5% vs. 68.9%). Differences were also found in the pre-operative length of stay of patients with proximal femoral fractures (UKB: 0.97 days, HUS: 1.57 days). The productivity of the operating unit was quite similar in the hospitals. In terms of ED mortality, no statistically significant differences were found. CONCLUSIONS: The results of the present study showed significant differences in the use of resources and throughput times in trauma patient processes between Finnish and German hospitals. However, due to system-level differences between German and Finnish healthcare, the results cannot be directly transformed into development proposals for the organizations. On the other hand, in spite of certain differences regarding the healthcare systems, the demographic data of the trauma patients and medical procedures are comparable. Based on the present study, the ED process of severe trauma, pre-operative care, and operating unit processes were the most comparable parts of trauma care between the hospitals. The study also showed that the international benchmarking approach could be used to reveal bottlenecks in system-level policies and practices.

Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study.

BACKGROUND: Early operative treatment of combined anterior cruciate and medial collateral ligament injuries has frequently led to motion complications and slow quadriceps muscle power gains. The purpose of the present study was to evaluate the effect of early repair or nonoperative treatment of a concomitant medial collateral ligament injury on range of motion of the knee and quadriceps muscle strength in patients with combined injuries. METHODS: Forty-seven consecutive patients with combined anterior cruciate and grade-III medial collateral ligament injuries were randomized into two groups. The medial collateral ligament was repaired in Group I (n = 23) and was treated nonoperatively in Group II (n = 24). In both groups, the torn anterior cruciate ligament was treated with early reconstruction. The patients were evaluated on the basis of sequential range-of-motion measurements, the one-leg-hop test, and isokinetic muscle power measurements at the time of follow-up, and the findings were compared between the two treatment groups. RESULTS: All patients achieved full knee extension. At all follow-up intervals the flexion deficit was greater in the group that had been managed with surgical repair of both ligaments, but the difference was significant only at six weeks (100 degrees compared with 112 degrees; p = 0.009), twelve weeks (119 degrees compared with 128 degrees; p = 0.043), and thirty-six weeks (130 degrees compared with 136 degrees; p = 0.011) after the operation. The difference between the groups was not significant at fifty-two weeks (132 degrees compared with 137 degrees) or 104 weeks (134 degrees compared with 137 degrees). The quadriceps muscle power deficit at fifty-two weeks was 30.7% in the group that had been managed with combined repair and 20.5% in the group that had been managed with anterior cruciate ligament reconstruction only (p = 0.015). At 104 weeks, the deficits were 14.4% and 9.7%, respectively (p = 0.2). CONCLUSIONS: Early operative treatment of combined anterior cruciate and medial collateral ligament injuries is possible without increased long-term mobilization complications. The rehabilitation period is long, and aggressive physiotherapy is recommended. However, nonoperative treatment of the torn medial collateral ligament allows faster restoration of flexion and quadriceps muscle power. Our results favor nonoperative treatment of the torn medial collateral ligament in patients with combined injuries.

What is the best workflow for an operating room? A simulation study of five scenarios.

Parallel induction of anesthesia improves operating room (OR) efficiency. To support decision-making as to optimal facilities and optimal use of resources, we compared the cost-efficiency of several workflow models of parallel induction to that of the traditional model, using discrete-event simulation. For each scenario, average number of procedures performed, surgery time, daily over- and underutilized time, and staffing costs per operation were assessed. We also studied whether scheduling short and long procedures in separate rooms would amplify the effects of the parallel processing. All parallel work-flow models demonstrated better cost-efficiency than the traditionally sequenced working pattern. Staffing costs per procedure were 7% lower in the best induction model than in the traditional model. When short procedures were scheduled separately, differences between induction models were small.

The efficacy of magnetic resonance imaging in acute multi-ligament injuries.

This study compares MRI with examination under anaesthesia to surgical findings in evaluating soft tissue injuries in acute multi-ligament knee trauma. Pre-operative MRI was done for 44 patients who underwent surgery for grade III ACL and grade III medial collateral ligament (MCL) injury. In 21 cases both ACL and MCL were treated surgically, but in 23 only ACL. Intra-operative and MRI findings were compared. Accuracy of MRI for medial meniscal tears was 88.6%, sensitivity 80%, and specificity 91.2%; accuracy for lateral meniscal tears was 72.7%, sensitivity 55% and specificity 87.5%. Accuracy and sensitivity for severity of ACL tear was 93.2% and of MCL tear 86.4%. In 88.6% of the knees, bone bruises were visible, with anterolateral femoral and posterolateral tibial bone bruise being the most common. MRI revealed no chondral lesion, but arthroscopy revealed 11. In combined ACL-MCL ruptures, the incidence of concomitant injuries is high and the injuries are best detected with MRI.

Helsinki Trauma Outcome Study 2005: Audit on Outcome in Trauma Management in Adult Patients in Southern Part of Finland.

The outcome performance of the adult patients trauma care in Helsinki University Hospital was compared with a sample of English hospitals. This was a first time such an audit on trauma care was conducted in Finland. Helsinki University Hospital submitted the Trauma Audit and Research Network (TARN, UK) data of adult trauma patients during 1 year period (from 1 September 2004 to 31 August 2005). Patients younger than 16 years were excluded. The outcome performance was assessed by TARN prediction model using the TARN database as reference. There were total of 1,717 patients in Helsinki and 16,774 patients in English hospitals fulfilling the study inclusion criteria, and 1,635 (95.2% of total) eligible patients in Helsinki and 15,269 (91.0% of total) in England were used for analysis. The patients were older and the mean ISS was higher in Helsinki (mean ISS in Helsinki 14 vs. 11 in England). The standardized W statistic (a measure of survival variation from the expected mean, per 100 patients) was + 3.0 (confidence intervals + 2.3 to + 3.8) for Helsinki University Hospital and + 0.2 (confidence intervals -0.1 to 0.4) for English hospitals. These results suggest that the organization of trauma care in Helsinki University Hospital area is more effective in preventing death after trauma in adults than that covering the present sample of English hospitals.

Modified and new approaches for pelvic and acetabular surgery.

We analysed outcomes of new operative techniques for open reduction and internal fixation in 120 consecutive patients with fractures of the pelvic ring and 164 patients with acetabular fractures treated between 1989 and 1999. An anterior extraperitoneal approach was performed through a low midline incision to fix the anterior and lateral parts of the pelvis and for central involvement of different types of acetabular fractures. The anterior approach was combined with a lateral incision on the lateral crest for fractures of the iliac wing and with a posterior approach for sacroiliac injuries, or with Kocher-Langenbeck approach for posterior acetabular involvements. The complication rate of the new techniques was low. Heterotopic ossification was rare. The functional recovery was good in 66 of the 81 patients with an unstable C-type pelvic injury, in 18 out of the 20 patients with a lateral compression, B-2-type injury and 13 out of 19 patients with a open book, B-1-injury. Neurological recovery was observed after adequate reduction in those patients suffering from lesions of the sacral plexus. The radiographic result was good in 73, 20 and 17 of the patients groups, respectively. The Harris Hip Score was more than 80 in 75% of the 164 patients with an acetabular fracture. The radiological result was good (residual displacement 0-2mm) in 84%, fair (3-5mm) in 9% and poor (more than 5mm) in 7%. The new methods are less invasive than the basic approaches described in the literature. The whole pelvic ring, as well as all the acetabular fracture combinations may be treated with the combination of approaches used in the present study.

MRI of menisci repaired with bioabsorbable arrows.

OBJECTIVE: To analyze with conventional magnetic resonance imaging (MRI) the signal appearance of menisci repaired with bioabsorbable arrows. DESIGN AND PATIENTS: Forty-four patients with 47 meniscal tears treated with bioabsorbable arrows underwent follow-up conventional MRI examination. The time interval between the surgery and MRI varied from 5 to 67 months (mean 26 months). Twenty-six patients also had concurrent repair of torn anterior cruciate ligament. The following grades were used to classify meniscal signal intensity: (a) G0; low signal intensity on all sequences and regular configuration in every plane, (b) G1; increased signal intensity within the meniscus, not extending to the meniscal surface, (c) G2; increased signal intensity linear in shape, which may or may not communicate with the capsular margin of the meniscus, without extending to the meniscal surface, and (d) G3; increased signal intensity extending to the meniscal surface. RESULTS: Thirteen menisci (27.5%) had normal signal intensity, 13 menisci (27.5%) Grade 1 signal intensity, 9 menisci (19%) Grade 2 signal intensity and 12 menisci (26%) Grade 3 signal intensity. The time difference between operation and MRI was statistically significant between the G0 (36 months) and G3 groups (14 months; P = 0.0288). There was no statistical significance in different grades between medial and lateral meniscus or between patients with operated or intact ACL. On physical examination sixteen patients reported slight symptoms, seen evenly in each group. CONCLUSION: No difference was seen in different grades between patients with operated or intact ACL. The highest incidence of menisci with a Grade 3 signal was seen in patients where surgery was within the last 18 months.

Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study.

BACKGROUND: The apparent consensus is that solitary medial collateral ligament rupture can be treated nonoperatively, but treatment of severe combined ruptures of the medial collateral ligament and anterior cruciate ligament remains controversial. HYPOTHESES: Nonoperative and early operative treatments of grade III medial collateral ligament rupture lead to similar results when the anterior cruciate ligament is reconstructed in the early phase. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Forty-seven consecutive patients with combined anterior cruciate ligament and grade III medial collateral ligament injuries were randomized into 2 groups. The medial collateral ligament injury was treated operatively in group 1 (n = 23) and non-operatively in group 2 (n = 24). In both groups, the anterior cruciate ligament injury was treated with early reconstruction, using bone-patellar tendon-bone graft and interference screw. Two years postoperatively, knee stability was measured with a KT-1000 arthrometer and Telos valgus radiography and knee extension strength with a Biodex dynamometer and a 1-legged hop test. An International Knee Documentation Committee evaluation form and Lysholm score were completed. RESULTS: All 47 patients were available for clinical evaluation for a mean of 27 months (range, 20-37 months) after surgery. There were no statistically significant differences between the 2 groups with respect to subjective function of the knee, postoperative stability, range of motion, muscle power, return to activities, Lysholm score, and overall International Knee Documentation Committee evaluation. The subjective outcome and Lysholm score were good and anteroposterior knee stability excellent in both groups. CONCLUSION: Nonoperative and operative treatments of medial collateral ligament injuries lead to equally good results. Medial collateral ligament ruptures need not be treated operatively when the anterior cruciate ligament is reconstructed in the early phase.

Outcome of operatively treated type-C injuries of the pelvic ring.

BACKGROUND: Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique. PATIENTS: We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques. RESULTS: Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%. INTERPRETATION: Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.

Retrograde intramedullary nailing in distal femoral fractures--results in a series of 46 consecutive operations.

We present a series of 44 consecutive patients with 46 distal femoral fractures, who were treated with a retrograde intramedullary nail (Distal Femoral Nail (DFN)). Operational data, per- and post-operative complications and the outcome were studied retrospectively after a mean follow-up of 9 months. The final union rate was 95%, with a mean union time of 17.5 (8-68) weeks. Restoration of the limb axial alignment and length was inadequate in two cases, whereas three losses of reduction and one non-union were observed. Two cases of distal locking screw breakage were also observed. Moreover, one patient suffered from an iatrogenic lesion of the branch of the deep femoral artery. No deep, but three superficial infections were observed. In conclusion, our results suggest that DFN is a reliable alternative in distal femoral fracture treatment with a low complication rate.

Two-incision technique for rotational acetabular osteotomy: good outcome in 35 hips.

We have developed a 2-incision technique for rotational acetabular osteotomy. This includes both an extraperitoneal and an anterolateral exposure of the pelvic bones allowing an unconstrained approach without dissection of the muscle insertion. 2 plates are used to stabilize the osteotomy and full range motion of the hip is permitted within 2 days of surgery, while weight bearing is restricted for 6 weeks after the operation. We reviewed the complications and technical results in 27 patients (28 hips) after a minimum follow-up of mean 3 (1-5) years. No major surgical complications occurred, but dysfunction of the lateral femoral cutaneous nerve occurred frequently (14 patients). The radiographical correction of the femoral head covering was similar to those in previous reports of rotational osteotomy. The range of hip motion was not affected by the operation. A significant increase in the mean Merle D'Aubigné and Harris Hip scores was observed in a subgroup of 20 patients with a minimum follow-up of 2 years. In conclusion, the method we have used is safe and the early results are satisfactory.

Factors predisposing to dislocation of the Thompson hemiarthroplasty: 22 dislocations in 338 patients.

In a series of 338 patients, we have retrospectively analyzed technical and anatomical factors, which may predispose to a dislocation of the Thompson hemiprosthesis. 22 patients (7%) had at least 1 dislocation during the 6-month follow-up. The most significant independent factor predisposing to dislocation was the use of a posterior approach (dislocation rate 16%). We examined the radiographs and data on operations in the 22 patients, using 79 random patients without dislocation as controls. Factors correlating with an increase in the incidence of dislocation were the length of the residual femoral neck > 0.5 cm in short patients (< 165 cm), and considerable change in the postoperative offset of the hip. Acetabular measurements showed no correlation to the dislocation. Our findings suggest that the main factors predicting dislocation are technical and not related to anatomical measurements.

Surgical procedure skills of graduating medical students: effects of sex, working, and research experience.

BACKGROUND: Surgical procedures constitute an important part of every physician's daily practice. However, few studies have investigated the surgical skills of graduating medical students and, especially, factors that might be related to their degree of surgical competence. The present study sought to gather information on the basic surgical skills of graduating medical students and to establish whether factors influencing the students' competence could be identified and used to improve the teaching of basic surgical skills at medical schools. METHODS: A questionnaire was sent to all final-year medical students in Finland in 1997. It was returned by 404 (participation rate 80.2%) students. The questionnaire included questions on the theoretical knowledge and successful performance of 10 basic surgical procedures: abdominal paracentesis, application of Sengstake-Blakemoore tube, rubber-band ligation of hemorrhoids, reposition and casting of Colles' fracture, knee arthrocentesis, application of tibial traction, evacuation of subcutaneous abscess, male bladder catheterization, suprapubic catheterization, and nevus excision. RESULTS: Over 90% of the final-year medical students knew the theory of performing reposition and casting of Colles' fracture, knee arthrocentesis, urinary tract catheterization, and nevus excision, but only 32% (124/393) knew the theory of applying the Sengstake-Blakemoore tube. Nevus excision had been successfully performed by over 90% of the students. Of the emergency or duty procedures, application of the Sengstake-Blakemoore tube and abdominal paracentesis had been successfully performed by 1% (4/393) and 8% (32/393) of the students, respectively, whereas Colles' fracture reposition and suprapubic catheterization had been successfully performed by 46% of the students (182/393 and 179/393, respectively). The age-adjusted odds ratios for performing Colles' fracture reposition (OR 1.59; 95% CI 1.01 to 2.50), application of tibial traction (2.00; 1.03 to 3.89), evacuation of subcutaneous abscess (2.13; 1.25 to 3.62), and suprapubic catheterization (2.23; 1.21 to 4.09) were significantly higher among males than females. Students with working experience had higher odds ratios for performing suprapubic catheterization (OR 6.75; 95% CI 1.99 to 22.84), nevus excision (5.69; 2.49 to 13.0), reposition and casting of Colles' fracture (1.72; 1.01 to 2.94), knee arthrocentesis (4.78; 2.67 to 8.53), and evacuation of subcutaneous abscess (12.9; 6.12 to 27.1) than students without such experience. Students who had done extracurricular research had significantly lower odds ratios for performing evacuation of subcutaneous abscess (0.58; 0.34 to 0.99) than students without such experience. When the five medical faculties in Finland were compared, the highest odds ratios for performing procedures were at the university in which a student logbook was systematically used. CONCLUSIONS: Final-year medical students have fairly good theoretical knowledge of basic surgical procedures, but the successful performance rates of these procedures range from 1 to 90%. Males have performed surgical procedures significantly more often than females. Working experience clearly enhanced the surgical skills of medical students. However, research experience may impair the learning of these procedures. The systematic use of logbooks seems to be useful.