In summer 2001, Mr Britten undertook a fellowship in the application of the Ilizarov method under the supervision of Professor Vladimir I. Shevtsov at the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics in Kurgan, Russia.  The programme included an overview of Ilizarov techniques, anatomy for pin placement, preoperative planning, bone model workshops and tips for stable frame construction, supervised surgery sessions, leg lengthening and bone transport techniques, post-operative management of wound sites and complications, physiotherapy and rehabilitation, and opportunity for emergency on-call for trauma.  The fellowship followed on from an initial course in Ilizarov application for foot, ankle and distal tibial pathology; including lectures, discussions and theatre sessions in foot and ankle fractures, pilon fractures, foot deformity correction, calcaneal fractures and post-traumatic conditions.

Mr Britten returned to the Ilizarov Centre for a further period of private study in the Department of Closed Trauma 1, dovetailing with a conference on the use of the Ilizarov method in trauma treatment in summer 2002.  A third visit to Kurgan was undertaken to attend a conference on the use of the Ilizarov method in the treatment of osteomyelitis in summer 2003.  In autumn 2004, Mr Britten attended a conference on the basic science of distraction histiogenesis and spent further time in the Department of Bone Infection, working under the tuition of Head of the Department, Professor Nikolai Mikhailovich Klyushin.

In June 2006, Mr Britten was invited to the Conference of Young Scientists at the Ilizarov Centre to celebrate the 85th anniversary of Professor Ilizarov’s life, and invited to make two presentations – on the role of crusts in Ilizarov fixator pinsite care, and on Flap & Frame, the combined orthoplastic management of adult open tibial fractures by microvascular free tissue transfer and fine wire circular frame fixation.

Following the Calman restructuring of the old registrar and senior registrar training grades, Mr Britten was appointed as Specialist Registrar in Trauma and Orthopaedics in Bristol, in autumn 1996.  In addition to general orthopaedic training in total joint replacement, arthroscopy, upper limb surgery, hand surgery, paediatric and young adult orthopaedics, foot and ankle surgery, and spinal surgery; Mr Britten undertook 14 months of training in complex trauma and limb reconstruction at Bristol Royal Infirmary, under the supervision of Mark Jackson and Professor Roger Atkins.  Early in his registrar training, Mr Britten had also spent 6 months in Gloucester working for Christopher Curwen, widely acknowledged to be an outstanding orthopaedic trauma surgeon and orthopaedic trauma teacher.  While in Gloucester, Mr Britten learned about basic and advanced nailing and plating techniques, about the holistic management of the trauma patient, and how to swear in Afrikaans.

After leaving the British Army, Mr Britten completed his basic surgical training rotation at Royal United Hospital, Bath.  His rotation gave him exposure to trauma and orthopaedics, general and abdominal surgery, breast and endocrine surgery, urological surgery; and vascular surgery, working for former Vice President of the Royal College of Surgeons of England, Professor Michael Horrocks.  During his rotation Mr Britten was successful in passing the primary FRCS examination in anatomy, physiology and pathology, and the ‘final’ Clinical Surgery in General fellowship FRCS(Eng).  During that time he also completed his AO Basic course on fracture fixation in Davos, Switzerland.

Mr Britten undertook his House Officer and early Senior House Officer posts in the NHS in England and with the British Army.  His post as House Surgeon at Princess Alexandra Hospital, RAF Wroughton in 1991 involved the surgical care of service personnel evacuated from the First Gulf War, including soldiers from the Royal Green Jackets, Royal Regiment of Fusiliers, Army Air Corps, and UK special forces.

In summer 1988, as a lieutenant in the British Army, Mr Britten was on attachment to British Military Hospital Dharan, an 80 bed static acute unit, located in a military cantonment as a part of British Gurkhas Nepal.  The local town of Dharan lies in an earthquake zone, and the military hospital was designed to withstand major tremors.  At 0450hrs on 21 August 1988, an earthquake measuring 6.7 on the Richter scale, lasting about 40 seconds, devastated parts of the town of Dharan and many hill villages in East Nepal.  715 people were killed, 1,135 injured, and about 18,000 dwellings were destroyed or damaged (see – Guy P et al, Operation Nightingale: The role of BMH Dharan following the 1988 Nepal Earthquake.  Journal of the Royal Army Medical Corps 1990; 136: 7-18).  The earthquake caught many victims attempting to escape from their beds, and collapsing ceilings of multi-storey brick and clay-mortar buildings accounted for many axial skeletal injuries, pelvic and lower limb fractures.  For the first 48 hours, the hospital provided the most significant medical relief effort in East Nepal, and provided the only sophisticated surgical facility.  A Casualty Clearing Station was opened and the hospital progressively expanded to 212 beds in tented wards.  On the first day alone, the CCS triaged 450 patients, many more received first aid and were discharged without documentation, and 89 of the most seriously injured were admitted.  After 48 hours, BMH Dharan was augmented by personnel from BMH Hong Kong and air-portable 22 Field Hospital.  In total 330 surgical procedures were carried out to treat earthquake victims.  Mr Britten’s early experience in mass casualty and disaster management during Operation Nightingale stimulated his interest in orthopaedic trauma, and ultimately led to him pursuing a career as a consultant in trauma and orthopaedic surgery.