In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies was extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home. There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduce mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery apart from one study of 399 patients, which reported an increased mortality and morbidity for those operated on within 24 hours of admission. In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay

To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC. Retrospective review. All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3). Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups. A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86). The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03. When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05). When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009). There was no difference in survival or complications between the groups. Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates

Introduction: Ankle fractures are one of the most common injuries treated by the orthopaedic surgeon. The general recommendation is if surgical treatment is not carried out within the first 24 hours from the injury, then it should be delayed for about 5-7 days to reduce the risk of wound complications associated with limb swelling. The aim of our study was to see whether timing of surgery significantly affects the outcome or wound complications following internal fixation of displaced ankle fractures. METHOD: We retrospectively analysed the medical records of 37 patients with ankle fractures, who were admitted to the orthopaedic department at our Hospital between May 2003 and May 2004. The fractures were classified according to Dennis-Weber classification. Open reduction and rigid internal fixation was performed according to the techniques of the Association for the Study of Internal Fixation (AO Group). RESULTS: The mean age of the patients was 41.6 years (range 19-70). According to Denis-Weber classification 2 (6%) were type A, 26 (70%) were type B and 9 (24%) were type C fractures. The mean delay before surgery was 2.4 (0-9) days. The mean length of hospital stay was 4.6 (1-13) days. 35% of the fractures were operated between the second and fourth days after the injury without any increase in wound or fracture related complications. There were no cases of wound infection or dehiscence. Although there was one case of delayed union of medial malleolus, the overall union rate was 100%. CONCLUSION: We conclude that for ankle fractures that are not operated on within the initial 24 hours from the injury, delayed treatment could be instituted as soon as patient and limb factors permit and rigid adherence to waiting times of 5-8 days is not necessary

Introduction: Ankle fractures are one of the most common injuries treated by the orthopaedic surgeon. The general recommendation is if surgical treatment is not carried out within the first 24 hours from injury, then it should be delayed for about 5–7 days to reduce the risk of wound complications associated with limb swelling. The aim of our study was to see whether timing of surgery affects the relative risk of skin complications following internal fixation of ankle fractures. Method: We analysed medical records of 102 patients with closed ankle fractures admitted to the orthopaedic department at our hospital between May 2003 and May 2005. The fractures were classified according to the Weber-AO classification. Open reduction and internal fixation was performed according to the techniques of the AO Group. Results: The mean age of patients was 43 years(range 13–87). According to the AO classification, 3 were type A(A1–3), 77 were type B(B1-16, B2-42, B3-16), 17 were type C(C1-2, C2-11, C3-4), 4 were isolated medial malleolus and 1 was Salter-Harris type 2 fractures. The mean delay before surgery was 3(0–18) days. The mean length of hospital stay was 6(1–44) days. Out of 102 patients, 53 of the patients were operated within 24 hours, 22 were operated from 24–72 hours, 15 within 4 to 7 days and the rest were operated within 7–18 days. The main reasons for delay were either failed initial conservative management or late presentation. There was one case of superficial wound infection, deep vein thrombosis, neuroma and delayed union of medial malleolus each. Conclusion: We conclude that for ankle fractures that are not operated on within the initial 24 hours from the injury, delayed treatment could be instituted as soon as patient and limb factors permit and rigid adherence to waiting times of 5–7 days is not necessary

Background: The timing of surgery for closed ankle fracture is controversial. Conventional teaching recommends either immediate surgery or a delay of 5–7 days in order to minimise soft tissue complications. However, there have been no large studies to produce clear guidelines and the literature is conflicting. Some authors suggest that delayed surgery results in increased risk of wound complications, less satisfactory rate of anatomical reduction, increased hospital stay and health service cost. Objective: We aimed to determine whether surgery can be safely performed in an intermediate time frame with respect to soft tissues complications. Method: We performed retrospective analysis of case notes and plain radiographs of 85 patients undergoing open reduction and internal fixation for closed ankle fractures at our unit in 2004. Data was analysed using the StatView statistical analysis program. Continuous variables were assessed for association with wound complication by means of an unpaired t-test. Nominal variables were assessed using Fisher’s exact test. Results: The overall rate of infection in our population of 85 patients was 9.4%. This comprised 7 superficial wound infections and one deep infection. Patients were classified into early (within 1 day), intermediate (between 2–6 days) and delayed (after 6 days) groups according to the time delay prior to surgery. Only 1 patient in the intermediate surgery group developed infection compared to 6 in the delayed group and this was statistically significant (p = 0.046). Conclusion: We suggest that with experience, meticulous soft tissue handling and good operative technique, delaying surgery until swelling has subsided is unnecessary in the majority of patients and is associated with a higher risk of wound complication

The purpose of this study was to investigate the importance of the timing of surgery for disease-free survival (DFS). The increasing efficacy of neo-adjuvant chemotherapy in Ewing’s sarcoma modifies the prognostic factors. In a recent monocentric study the classical prognostic value of size and location of the primary disappeared (. Delepine G, Alkallaf S. . J. Chem. 1997. ;. 9. :. 352. –63. ). This study confirmed the value of histologic response and pointed out the importance of dose intensity of VCR and ACTD. However, the role of local treatment could not be significantly demonstrated because the number of patients was too small. Seventy-five patients with an average age of 19 years (range 4 to 40) years with Ewing’s sarcoma of bone fulfilled the inclusion criteria for this study: localised tumour at first screening (CT of lungs + bone scan) and location of the tumour in resectional bones (limb, scapula, innominate, rib, maxilla, skull). Metastatic patients and vertebral locations were excluded. The patients received multi-drug chemotherapy and were treated by surgery and radiotherapy in cases of bad responders and/or marginal surgery. The histologic response was evaluated according to Picci’s criteria (. Picci, A. . J Clin Oncol. 1993. ;. 11. :. 1793. –99. ). The duration of local treatment was calculated from biopsy to surgery in weeks. After a mean follow-up of 54 months, 41 patients were in first complete remission. Patients operated before the tenth week had a higher chance (68%) of first complete remission than patients operated later (DFS: 43%). The difference is significant (p< 0.03). Further analysis shows that the difference is due to late local control, which causes a dismal prognosis for bad responders. Local treatment must be performed early, especially when histologic response is incomplete or uncertain. Preoperative chemotherapy that is too long increases the risk of metastases in bad responders. These factors must be taken into account when analysing multicentre protocols

The purpose of this study was to investigate the importance of the timing of surgery for disease-free survival (DFS). The increasing efficacy of neo-adjuvant chemotherapy in Ewing’s sarcoma modifies the prognostic factors. In a recent monocentric study the classical prognostic value of size and location of the primary disappeared (. Delepine G, Alkallaf S. . J. Chem. 1997. ;. 9. :. 352. –63. ). This study confirmed the value of histologic response and pointed out the importance of dose intensity of VCR and ACTD. However, the role of local treatment could not be significantly demonstrated because the number of patients was too small. Seventy-five patients with an average age of 19 years (range 4 to 40) years with Ewing’s sarcoma of bone fulfilled the inclusion criteria for this study: localised tumour at first screening (CT of lungs + bone scan) and location of the tumour in resectional bones (limb, scapula, innominate, rib, maxilla, skull). Metastatic patients and vertebral locations were excluded. The patients received multi-drug chemotherapy and were treated by surgery and radiotherapy in cases of bad responders and/or marginal surgery. The histologic response was evaluated according to Picci’s criteria (. Picci, A. . J Clin Oncol. 1993. ;. 11. :. 1793. –99. ). The duration of local treatment was calculated from biopsy to surgery in weeks. After a mean follow-up of 54 months, 41 patients were in first complete remission. Patients operated before the tenth week had a higher chance (68%) of first complete remission than patients operated later (DFS: 43%). The difference is significant (p< 0.03). Further analysis shows that the difference is due to late local control, which causes a dismal prognosis for bad responders. Local treatment must be performed early, especially when histologic response is incomplete or uncertain. Preoperative chemotherapy that is too long increases the risk of metastases in bad responders. These factors must be taken into account when analysing multicentre protocols

37 patients (38 hips) underwent sub-capital osteotomy for slipped upper femoral epiphysis (SUFE) between 1980 and 1999. All slips were severe, and 28 (74%) were unstable. Patients were followed-up at a mean 6. 9 years (range 2. 2–20 years) to identify the relationship between the timing of surgery and complications. Stable slips underwent urgent elective operations. Unstable slips, admitted as emergencies, were operated upon following two different protocols. 17 cases underwent the Dunn procedure on the next available list at a mean 1. 7 days after admission. 21 cases underwent the Fish procedure after a mean 22. 2 days of bedrest on “slings and springs”. Of 23 patients (24 hips) who suffered no complications and for whom on Iowa Flip Score was available, the means score was 96. 5 (range 91–100). There were 6 cases of Avascular Nervosis (AVN) (16%), all occurring after unstable slips, and 4 cases of chondrolysis (10%). Amongst unstable slips, shorter periods of pre-operative bedrest were associated with a higher incidence of avascular necrosis (AVN) (p< 0. 025). Direct comparison of the two surgical procedures showed no statistically significance difference in the incidence of AVN. Sub-capital osteotomy is valid treatment for severe SUFE. More than 20 days of pre-operative bedrest decreased the incidence of AVN in unstable SUFE

We reviewed 87 patients who underwent revision anterior cruciate ligament (ACL) reconstruction. The incidence of meniscal tears and degenerative change was assessed and related to the timing from primary ACL graft failure to revision ACL reconstruction. Patients were divided into either an early group (revision surgery within 6 months of graft failure) or a delayed group. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group compared to the early group (53.2% vs 24%, p < 0.01, Mann- Whitney U test). No patients in the early group had advanced degenerative change (SFA grades 3 or 4), compared with 12.9% of patients in the delayed group. There was no significant difference in the incidence of meniscal tears between the two groups. In conclusion, the findings of the study support the view that patients with a failed ACL reconstruction and symptomatic instability should have an early revision reconstruction procedure carried out to minimise the risk of articular degenerative change.

Introduction: Ankle fractures are among the commonest orthopaedic injuries. A delay in operating is often due to the swelling associated with such fractures. On the other hand, the delay in operative fixation beyond 24 h from injury is associated with a lengthening of hospital stay which costs approximately £225 per patient per day for an acute trauma bed.

Objectives: The aim of this study was to analyse the relationship between the delay in surgical intervention of open reduction and internal fixation of ankle fractures from presentation due to ankle swelling, and the length of hospital stay and postoperative complications.

Patients and Methods: A retrospective study of 145 consecutive patients treated for ankle fractures over a period of 12 months between January and December 2008. results were collated excluding talar and pilon fractures. Emergency department presentation times were noted and time of anaesthetic to determine surgical delay. Notes were reviewed for inpatient stay and postoperative complications.

Results: There were 62 male and 83 female patients with a mean age of 49 years. In total, 117 (80%) patients were operated on within 24 hours of presentation (early group). 28 patients’ surgery was delayed beyond 24 hours (delayed group). Of the 117 patients the mean inpatient stay was 3.79 days (± 2.39) whereas in the delayed group the mean stay was 8.57 days (± 6.54). Of the delayed group, 57% of the cases had swelling as the cause of a postponed operation, whereas other causes included lack of theatre time and lack of fitness for surgery. In the early group, 5 patients (4.27%) had wound infections and one patient had a chest infection (0.85%). Four patients (14.28%) from the delayed group developed wound infections all of whom were from patients with ankle swelling.

Conclusion: We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles prior to the development of swelling as this would result in improved patient outcome and significant financial savings. If an operation is not feasible within 24 hours of admission and the ankle is swollen resulting in a high operative risk, we recommend sending the patient home for a period of 5–7 days with advice on RICE and anticoagulation which would both permit surgery and cut down costs.

Aims: The purpose of the study was to determine the relationship of preoperative health status and surgery delay on postoperative complications and mortality in patients with hip fracture Methods: 195 patients with hip fracture were admitted to the Institute between 1997 and 2001. Information on the demographics, pre-existing medical conditions, type of fracture, operation and anesthesia, and postoperative complications during hospitalization was obtained from the medical records. Preoperative health status was assessed by the ASA classification. Medical records and the telephone interviews were used for follow-up on the patient’s vital status. Results: Analysis include patients who were 65 and older, cognitively intact, living at home and able to walk before surgery. 64% were female with femoral neck fracture. More than half had two or more pre-existing medical conditions and ASA grade III or IV. Follow-up period averaged 24 months (6 to 60). The overall mortality was 15% at one year, 23% at two years and 30% at three years. The three year mortality was less for ASA I and II patients than for ASA III, IV and V group. We found difference in mortality between patients having surgery within 24 hours of admission (25%) and those with operative delay beyond 24 hours of admission (45%). Conclusions: Operative treatment within 24 hours of admission showed lower mortality rate than in patients having surgery beyond 24 hours of admission in conjunction with preoperative ASA classification

Aims

To determine whether a delay of greater than 6 hrs from injury to initial surgical debridement and the timing of antibiotic administration affect infection rates in open long-bone fractures in a typical district general hospital in the UK.

Introduction:. Early stabilization has the potential to expedite early return to function and reduce hospital stay thus reducing cost to health care. A clinical audit was performed to test the hypothesis that early surgical stabilization lowers the rate of soft tissue complications and is not influenced by choice of distal fibular implants used for stabilization of ankle fractures. Methods:. All surgically treated adult patients with isolated unstable ankle fracture were included from April 2012 to April 2013 at a MTC in UK. Patients with poly-trauma were excluded. All patients underwent a standard surgical protocol: aim for early definitive surgical fixation (ORIF) within 24 hours however if significantly swollen than temporary stabilization with an external fixation followed by a staged definitive fixation. Results:. In total 172 consecutive unstable ankle fractures were included in one-year study period. Definitive fixation (ORIF) was achieved in 91% patients with only 9% patients required temporary stabilization with external fixation. Fibular locking plates were used in 59(38%) patients compared to conventional one-third tubular plates in 91(60%) patients. In ORIF group 42% (73) patients were operated within 24 hours of admission whilst 58% (83) under went early fixation after 24–72 hours. At one year follow up complications were recorded in 18(11%) patients including metal irritation requiring removal of implant in 6(4%) patients. Wound complications and deep infection leading to a further surgical procedure in 8(5%) patients. There was no statistical difference between complication rates (p=0.016) in early versus delayed fixation groups. Fibular locking plates were associated with higher soft tissue complications (13%) as compared with conventional plates (2%) (p=0.004). Conclusion:. Our study showed that the timing of the surgery has less influence on the complications of the ankle fracture fixation. However choice of implants requires careful consideration and we suggest caution against use of current fibular locking plates

Reviewing our experience of scoliosis in children with a Cavopulmonary Shunt or Fontan circulation and the cardiovascular challenges that this presents.

A notes and x ray review was performed. Special attention was paid to the changes in cardiovascular status whilst prone. The review was from first presentation to latest follow up.

There were 6 patients who underwent 7 major procedures between 2001 and 2009. All had cardiac procedures in early life. Both definitive fusion and growing instrumentation was used. All procedures were successful. Growing instrumentation allowed earlier primary surgery before completion of the Fontan circulation. All have been subsequently lengthened in a lateral position. The mean follow up is 56 months. There was one death 40 months following last surgery, cause unrelated to spinal surgery.

In the older patients with a completed Fontan significant blood loss was seen, due to the raised venous pressure required to run the Fontan, and occult hypotension seen as a climbing difference between Pulmonary Artery Wedge Pressure and Central Venous Pressure were common when prone.

We recommend early intervention, using instrumentation without fusion to correct the deformity over time and allow intervention prior to completing the Fontan circulation. As haemodynamic instability increases with increasing time in the prone position, surgery should be expedited rapidly.

Aims. Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

Abstract. Background. Multi-ligament knee injury is a rare but severe injury. Treatment strategies are challenging for most orthopedic surgeons & optimal treatment remains controversial. The purpose of our study was to assess clinico-radiological and functional outcomes after surgical management of multi-ligament knee injuries & to determine factors that could predict outcome of surgery. Materials And Method. It is a prospective observational study of 30 consecutive patients of Multi-ligament knee injury conducted between 2018–2020. All patients were treated surgically with single-stage reconstruction of all injured ligaments and followed standardized postoperative rehabilitation protocol. All patients were evaluated for Clinical (VAS score, laxity stress test, muscle-strength, range of motion), Radiological (stress radiographs) & Functional (Lysholm score) outcomes three times-preoperatively, post-operative 3 & 12 months. Results. At final follow up mean VAS score was 0.86±0.77. The anteroposterior & valgus-varus stress test showed ligament laxity >10mm (GradeD) in 93.3% patient which improved to <3mm (normal, GradeA) in 90% patients. Most patients (83.3%) had preoperative-range <100° and muscle strength of MRC Grade-3 which improved to >120° and muscle strength of MRC grade-5 at final followup. Lysholm score was poor (<64) in all patients preoperatively and improved to good (85–94) in 73.3%, excellent (>95) in 20% & fair (65–84) in 6.6% patients. The stress radiographs showed stable results for anterior/posterior & varus/valgus stress. All patients returned to their previous work. Factors that could predict outcomes of surgery are age, timing of surgery, type of surgery & associated injury. Conclusion. Early complete single stage reconstruction can achieve good functional results with overall restoration of sports & working capacity. Positive predictive factors for good outcome are younger age, early surgery & appropriate rehabilitation

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Whilst total hip replacement (THR) is generally safe and effective, pre-existing medical conditions, particularly those requiring inpatient admission, may increase the risk of post-operative mortality. Delaying elective surgery may reduce the risk, but it is unclear how long a delay is sufficient. We analysed 958,145 primary THRs performed for solely osteoarthritis April 2003-December 2018, in the NJR linked to Hospital Episodes Statistics to identify inpatient admissions prior to elective THR for 17 conditions making up the Charlson index including myocardial infarction, congestive heart failure, cerebrovascular disease and diabetes. Crude analyses used Kaplan-Meier and adjusted analyses used Cox modelling. Patients were categorised for each co-morbidity into one of four groups: not recorded in previous five-years, recorded between five-years and six-months before THR, recorded six-months to three-months before THR, and recorded between three-months and day before surgery. 90-day mortality was 0.34% (95%CI: 0.33–0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed 63 times increased hazard of death within 90-days if patients had an acute MI in the 3-months before their THR, compared to patients who had not had an MI in the five years before their THR (HR 63.6 (95%CI 50.8, 79.7)) This association reduced as the time between acute MI and THR increased. For congestive cardiac failure, the hazard in the same scenario was 18-times higher with a similar protective effect of delaying surgery. Linked NJR and HES data demonstrate an association between inpatient admission for acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the admission for acute medical conditions and THR in all diagnoses. This information will help patients with previous medical admissions and surgeons to determine optimal timing for surgery

Management of highly displaced acromioclavicular joint (ACJ) injuries remain contentious. It is unclear if delayed versus acute reconstruction has an increased risk of fixation failure and complications. The primary aim of this was to compare complications of early versus delayed reconstruction. The secondary aim was to determine modes of failure of ACJ reconstruction requiring revision surgery. A retrospective study was performed of all patients who underwent operative reconstruction of ACJ injuries over a 10-year period (Rockwood III-V). Reconstruction was classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method and post-operative complications were noted, with one-year follow-up a minimum requirement for inclusion. Fixation failure was defined as loss of reduction requiring revision surgery. 104 patients were analysed (n=60 early and n=44 delayed). Mean age was 42.0 (SD 11.2, 17–70 years), 84.6% male and 16/104 were smokers. No difference was observed between fixation failure (p=0.39) or deep infection (p=0.13) with regards to acute versus delayed reconstruction. No patient demographic or timing of surgery was predictive of fixation failure on regression modelling. Overall, eleven patients underwent revision surgery for loss of reduction and implant failure (n=5 suture fatigue, n=2 endo-button escape, n=2 coracoid stress fracture and n=2 deep infection). This study suggests that delayed ACJ reconstruction does not have a higher incidence of fixation failure or major complications compared to acute reconstruction. For those patients with ongoing pain and instability following a trial of non-operative treatment, delayed reconstruction would appear to be a safe treatment approach

Distal radius fractures (DRF) are very common injuries. National recommendations (British Orthopaedic Association, National Institute for Health and Care Excellence (NICE)) exist in the UK to guide the management of these injuries. These guidelines provide recommendations about several aspects of care including which type of injuries to treat non-operatively and surgically, timing of surgery and routine follow-up. In particular, current recommendations include considering immobilizing patients for 4 weeks in plaster for those managed conservatively, and operating on fractures within 72 hours for intra-articular injuries and 7 days for extra-articular fractures. With increased demands for services and an ageing population, prompt surgery for those presenting with distal radius fractures is not always possible. A key factor is the need for prompt surgery for hip fracture patients. This study is an audit of the current standard of care at a busy level 2 trauma unit against national guidelines for the management of DRFs. This retrospective audit includes all patients presenting to our emergency department from June to September 2018. Patients over 18 years of age with a diagnosis of a closed distal radius fracture and follow-up in our department were included in the study. Those with open fractures were excluded. Data was retrieved from clinical coding, electronic patient records, and IMPAX Client (Picture archiving and communication system). The following data was collected on patients treated conservatively and those managed surgically:- (1)Time to surgery for surgical management; (2)Period of immobilization for both conservative and operative groups. 45 patients (13 male, 32 female) with 49 distal radius fractures (2 patients had bilateral injuries) were included. Patients had mean age 63 years (range 19 to 92 years) 30 wrists were treated non-operatively and 19 wrists treated surgically (8 K-wires, 10 ORIF, 1 MUA). Mean time to surgery in the operative group was 8 days (range 1 – 21 days, median 7 days). Mean time to surgery for intra-articular fractures was 7 days (range 1 – 21) and 12 days for extra-articular fractures (range 4 – 20). Mean immobilization period in those treated in plaster is 6 weeks (range 4 – 13 weeks, median 5.6 weeks). At busy level 2 trauma units with limited theatre capacity and a high volume of hip fracture admissions, time to surgery for less urgent injuries such as wrist fractures is often delayed. National guidelines are useful in helping to guide management however their standards are often difficult to achieve in the context of increasing populations in urban areas and an ageing population