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

Aims. Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy. Methods. Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq). Results. Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation. Conclusion. These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients. Cite this article: Bone Joint Res 2023;12(10):657–666

Background. Hip fractures cost the NHS £2 billion per annum. British guidelines within 36 hours of admission. However, these guidelines do not consider the time the patient spends between injury and admission. Our study aims to investigate pre-hospital time (PHT) and its effect on outcomes. Primary outcome measures were mortality, length of stay (LOS), pressure sores and abbreviated mental test scores (AMTS). Methods. Hip fracture data was retrospectively collected from our hospital IT system (Clinical Workstation) between February and August 2020. Admission data, ambulance timings, and outcome data was extracted. Statistical analysis was performed using GraphPad Prism V9.5.1. Results. Two hundred eleven data sets were analysed. Mean age was 82.4, with 2:1 Females to males and median ASA of 3. The mean PHT was 690 minutes (85 to 6057). There was a positive correlation between increased PHT and mortality, though this did not reach statistical significance. There was a significant positive association between PHT and LOS (P=0.0027). Increased PHT was associated with lower admission AMTS (P<0.0001) and higher rate of pressure sore formation (P=0.0001). There was also a significantly positive correlation between PHT and time to mobility (P=0.049). Conclusion. There is an unobserved delay in hip fracture patients presenting to the hospital. Current treatment guidelines advocate early surgery but do not consider pre-hospital time. PHT in our patient population is 690 minutes on average, with increasing delay correlating with worse outcomes. Pre-hospital time should be considered when managing hip fracture patients with a view to expedite surgery and medical assessment

Waiting time to access medical care in Canada is 20% more than the international average. Delay in instituting care in trauma patients has been shown to correlate with higher complication rates and an increase in mortality. About 11% of all fractures occur in the femur and are usually treated operatively. Delay to operative treatment is a source of distress to patients and a major factor for poor outcome. Knowledge gaps exist for statistics on operative delay to fixation of femur fractures and the influence on complications and cost of treatment. This study describes (1) the effect of delay to fixation of femur fractures on complications and on the overall cost of care in hospitals in Quebec Province of Canada; and (2) proposes a time frame within which femur fractures should be operated on to minimize the risk of complications and reduce treatment cost. 6,520 adult patients operated for closed femoral fractures between July 1993 and December 2002 were reviewed. Data was accessed from (a) the Quebec Trauma Registry, (b) the hospitalised patients’ database, Maintenance et exploitation des données pour l’étude de la clientèle hospitalière (MED-ECHO) and (c) the medical insurance claims databases, Régie de l’assurance maladie Québec (RAMQ). Excluded were poly-trauma, open fractures, pathological fractures and delayed diagnoses beyond a week. Data was analysed using the SPSS software version 17.0. Cost analysis was carried out using parametric techniques (Student’s t-test and the generalized longitudinal model). Mean operative delay for femoral fractures was 26.3 hours. Delay was associated with increased complications, ICU stay, length of stay (LOS), hospitalization costs and out-patient follow-up treatment costs. There was a progressive increase in these adverse events which was quite significant after the first 48 hours. ISS >15 predisposed to prolonged ICU stay, LOS and increased cost of treatment. All femur fractures appeared to have a predilection for over-65-year-olds and women. The major cost drivers of operative femur fracture treatment were ISS>15, operative delay ≥48 hours, occurrence of complications, and re-operations. Minimizing operative delay in femur fractures will not only mitigate patient suffering, but also reduce treatment and follow-up costs

Aims. After failed acetabular fractures, total hip arthroplasty (THA) is a challenging procedure and considered the gold standard treatment. The complexity of the procedure depends on the fracture pattern and the initial fracture management. This study’s primary aim was to evaluate patient-reported outcome measures (PROMs) for patients who underwent delayed uncemented acetabular THA after acetabular fractures. The secondary aims were to assess the radiological outcome and the incidence of the associated complications in those patients. Methods. A total of 40 patients underwent cementless acetabular THA following failed treatment of acetabular fractures. The postoperative clinical and radiological outcomes were evaluated for all the cohort. Results. The median (interquartile range (IQR)) Oxford Hip Score (OHS) improved significantly from 9.5 (7 to 11.5), (95% confidence interval (CI) (8 to 10.6)) to 40 (39 to 44), (95% CI (40 to 43)) postoperatively at the latest follow-up (p < 0.001). It was worth noting that the initial acetabular fracture type (simple vs complex), previous acetabular treatment (ORIF vs conservative), fracture union, and restoration of anatomical centre of rotation (COR) did not affect the final OHS. The reconstructed centre of rotation (COR) was restored in 29 (72.5%) patients. The mean abduction angle in whom acetabular fractures were managed conservatively was statistically significantly higher than the surgically treated patients 42.6° (SD 7.4) vs 38° (SD 5.6)) (p = 0.032). We did not have any case of acetabular or femoral loosening at the time of the last follow-up. We had two patients with successful two-stage revision for infection with overall eight-year survival rate was 95.2% (95% CI 86.6% to 100%) with revision for any reason at a median (IQR) duration of follow-up 50 months (16 to 87) months following THA. Conclusion. Delayed cementless acetabular THA in patients with previous failed acetabular fracture treatments produces good clinical outcomes (PROMS) with excellent survivorship, despite the technically demanding nature of the procedure. The initial fracture treatment does not influence the outcome of delayed THA. In selected cases of acetabular fractures (either nondisplaced or with secondary congruency), the initial nonoperative treatment neither resulted in large acetabular defects nor required additional acetabular reconstruction at the time of THA. Cite this article: Bone Jt Open 2021;2(12):1067–1074

Aims. The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. Methods. A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. Results. Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. Conclusion. COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236–242

Aims. The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. Methods. A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively. Results. There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%). Conclusion. NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion. Cite this article: Bone Jt Open 2021;2(4):227–235

Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

Aims. With the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI). Methods. A total of 120 six-month-old Sprague-Dawley (SD) rats were randomized to six groups: Sham, sham + infection (Sham-Inf), sham with infection + antibiotics (Sham-Inf-A), ovariectomized (OVX), OVX + infection (OVX-Inf), and OVX + infection + antibiotics (OVX-Inf-A). Open femoral diaphysis fractures with Kirschner wire fixation were performed. Staphylococcus aureus at 4 × 10. 4. colony-forming units (CFU)/ml was inoculated. Rats were euthanized at four and eight weeks post-surgery. Radiography, micro-CT, haematoxylin-eosin, mechanical testing, immunohistochemistry (IHC), gram staining, agar plating, crystal violet staining, and scanning electron microscopy were performed. Results. Agar plating analysis revealed a higher bacterial load in bone (p = 0.002), and gram staining showed higher cortical bone colonization (p = 0.039) in OVX-Inf compared to Sham-Inf. OVX-Inf showed significantly increased callus area (p = 0.013), but decreased high-density bone volume (p = 0.023) compared to Sham-Inf. IHC staining showed a significantly increased expression of TNF-α in OVX-Inf compared to OVX (p = 0.049). Significantly reduced bacterial load on bone (p = 0.001), enhanced ultimate load (p = 0.001), and energy to failure were observed in Sham-Inf-A compared to Sham-Inf (p = 0.028), but not in OVX-Inf-A compared to OVX-Inf. Conclusion. In osteoporotic bone with FRI, infection was more severe with more bone lysis and higher bacterial load, and fracture-healing was further delayed. Systemic antibiotics significantly reduced bacterial load and enhanced callus quality and strength in normal bone with FRI, but not in osteoporotic bone. Cite this article: Bone Joint Res 2022;11(2):49–60

Various studies have demonstrated that the necessity for reversal of Warfarin through the use of Vitamin K (Vit K) in neck of femur fracture patients introduces increased duration of stay and poorer outcomes as measured by operative complications and mortality rate. One reason for this delay may be the time latency between admission and the clinicians decision to investigate the INR. In this study we aim to explore the different causes of latency which contribute to a delay to theatre and ascertain whether point of care testing may negate this. We carried out an audit of a cohort of neck of femur fracture patients between 2012 and 2015. Between September 2011 and September 2013, paper notes of 25 patients who were on warfarin at the time of sustaining a Neck of femur fracture (NOF) was obtained within Addenbrookes hospital archives. An additional 80 patients records from the year 2015 were retrieved from EPIC digital records. Time intervals were recorded as follows (from time of A&E assessment by Medical doctor); Interval to orthopaedic specialist assessment, Interval to first INR order, Interval to first INR result seen by specialist, Interval to first Vit K prescribed, Interval to first Vit K given, Interval to Second INR ordered, Interval to second INR seen by specialist, Interval to operation time (as determined by time of team briefing). Analysis of the time intervals as a proportion of total time elapsed between A&E assessment and Time to theatre was performed. Point of care (POC) testing of INR on admission to A&E was introduced and a symmetrical time period was analysed for the same intervals. The latency generated by time taken for a NOF to be assessed by an orthopaedic specialist occupied 8.60% of the total time, the interval between ordering and recording an INR value accounted for 7.96% of time to theatre, the interval between an INR being recorded and subsequently seen by a clinician accounted for 13.4% of time to theatre, the time between orthopaedic specialist assessment and prescription of Vit K took up 7.83% of the total time and the percentage time between Vit K prescription and administration was 12.3%. The time between the first dose of Vit K prescription and arriving at theatre accounted for 76.1% of latency and the time between viewing a second INR and time to theatre occupied 33% of the total time. Following introduction of POC INR testing, there was a statistically significant decrease in time taken for warfarin reversal and consequently a reduction between time of admission to time to theatres. NOF patients who are on warfarin at time of injury introduces complexity to surgical management and planning for theatre. In our audit we demonstrate that causes of delay are distributed throughout the pathway of care and there are several stages. POC INR testing represents an effective method of reducing this latency and improves patient outcome

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures. Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database. Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14). The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes

Aims. Cigarette smoking has a negative impact on the skeletal system, causes a decrease in bone mass in both young and old patients, and is considered a risk factor for the development of osteoporosis. In addition, it disturbs the bone healing process and prolongs the healing time after fractures. The mechanisms by which cigarette smoking impairs fracture healing are not fully understood. There are few studies reporting the effects of cigarette smoking on new blood vessel formation during the early stage of fracture healing. We tested the hypothesis that cigarette smoke inhalation may suppress angiogenesis and delay fracture healing. Methods. We established a custom-made chamber with airflow for rats to inhale cigarette smoke continuously, and tested our hypothesis using a femoral osteotomy model, radiograph and microCT imaging, and various biomechanical and biological tests. Results. In the smoking group, Western blot analysis and immunohistochemical staining revealed less expression of vascular endothelial growth factor (VEGF) and von Willebrand factor (vWF). The smoking group also had a lower microvessel density than the control group. Image and biochemical analysis also demonstrated delayed bone healing. Conclusion. Cigarette smoke inhalation was associated with decreased expression of angiogenic markers in the early bone healing phase and with impaired bone healing. Cite this article:Bone Joint Res. 2020;9(3):99–107

Purpose: We aimed to determine the effect of delay to surgery in hip fracture patients, including in hospital mortality, major complications, minor complications and length of hospital stay. Method: We identified 615 eligible patients from the VGH Orthopaedic Trauma database between 1998 and 2002. A thorough chart review was performed. Age, gender, time from admission to surgery, pre-existing medical comorbidity, length of acute care hospital stay, major medical complications, minor medical complications and in hospital death were recorded and categorized. Patients were categorized into three risk groups for pre-existing comorbidity, and three groups for delay to surgery (48 hours). Chi-squared tests were performed to determine the association of delay to surgery to death, major complications, minor complications and length of stay, as a categorical variable. Multivariate logistic regression analysis was used to evaluate these associations, while adjusting for age, gender, and pre-existing medical comorbidity. Anvoa test was used to evaluate the association between length of stay, as a continuous variable, and delay to surgery. Results There were 471 female patients, and 141 male patients. We identified 52 deaths (8.5%), 72 major complications (11.7%) and 238 minor complications (38.7%). The delay to surgery was < 24 hours in 346 patients (56.3%), 24–48 hours in 216 (35.1%), and > 48 hours in 50 (8.1%). The mean length of hospital stay was 23.4 days. Chi squared test showed no statistically significant association between delay to surgery and in hospital death (p= 0.787), despite a trend to increasing death (< 24 hours 8.1%, 24–48 hours 8.3%, > 48 hours 12.2%). There was no statistically significant association between delay and minor complications. Statistically significant associations between delay to OR and length of hospital stay (p= 0.0026), and the occurrence of a major complication (p=0.0085) were found. Regression analysis of major complications revealed an odds ratio of 1.47 for the > 48 hour group compared to the < 24 hour group, with a confidence interval of 1.15–1.87. Regression analysis did not show a statistically significant odds ratio for either death or minor complications. Conclusion: There is a trend to increasing mortality and minor complications with a delay to surgery in hip fractures. A statistically significant increase in major medical complications and length of hospital stay with delay to surgery was found in our group. Regression analysis including age, gender and pre-existing medical comorbidity supported the significance of the increased risk of major medical complications with delay, adjusted for age, gender, and pre-existing medical comorbidity

Background: Many patients with hip fractures have multiple medical problems that require attention. Pre-operative specialist interventions can often cause unnecessary delay. The aims of this study were to quantify the proportion of hip fracture patients that have an echocardiogram, to find out who and why the investigation was requested and to quantify the delay and its consequences. Methods: Retrospective review of all patients over a 9 month period that were admitted to hospital with a diagnosed hip fracture and had an echocardiogram as part of their pre-operative assessment. Results: 31 patients fulfilled the inclusion criteria. 23 sets of notes were reviewed. The majority of echocardiograms 17/23 were requested by orthopaedic SHOs without anaesthetic request. The reason for requesting the echocardiogram was the finding of a murmur on clinical examination. The average delay from admission to having an operation for patients who had an echocardiogram was 6.7 days (mode 5days). Mean delay to patients having the echocardiogram was 3.2 days (mode 2 days) and the delay to theatre after the echocardiogram was 3.5 days (mode 1 day). 15/23 patients had adverse effects. All but one patient had a routine uncomplicated anaesthetic. Conclusion: 6–7% of hip fractures have an echocardiogram. Junior members of the orthopaedic team request the majority of echocardiograms without anaesthetic input. Requesting an echocardiogram causes a delay from admission to theatre of approximately 1 week. Delay is associated with adverse effects, which may have fatal consequences for the patient

Aim. Bacterial identification in musculoskeletal infection is sometimes difficult and treatment strategy difficult facing unknown pathogen agent. We wonder if the delay of incubation and the preservation conditions of the samples between surgical procurement and subculture on plates have an influence. Method. 25 cm³ bone fragments were obtained from femoral heads retrieved during hip arthroplasty and excluded for bone transplant donation. Informed consent was obtained from the donor for research purpose. The study was approved by the Ethic Committee (N°B403201317725). Bone fragments were immersed for 30 minutes under gently agitation (140 RPM) at 35°C in a physiologic solution (negative control) or two solutions with two concentrations of staphylococcus epidermidis (0.5 Mc Farland or 1.5× 108 bacteria and 7.5×102 bacteria). Bone samples were separated and preserved at room temperature or at 4°C until seeded on Petri Plates to observe the influence of preservation conditions. Samples were plated after different delays (T0, T30min, T1H, T2H, T4H, T6H, T8H, T12H, T16H, T24H et T48H) to observe the influence of delay of culture. Experiments were repeated 5 times. When culture was positive, results were expressed with the number of colony. Results. We observed a regular diminution of number of colonies with the delay of culture. The number of colony goes to zero after 40 hours when the samples have been preserved at room temperature. Differences were not significant between preservation at room temperature and at 4°C for delay inferior to 04 hours but become significant for higher delay of culture in favor of low temperature preservation. With a low bacterial bioburden, no colony was recovered after a delay of 06 hours. False positive results were observed in 4% of the negative control. Conclusions. This experimental model demonstrates the negative influence of delay of culture and preservation at room temperature if the culture is delayed for more than 04 hours. The negative influence is more critical when facing low bacterial bioburden as it is generally the case in musculoskeletal infections. Our model do not included biofilm embedded bacteria and is limited to a staphylococcus epidermidis strain. The results could be worse with anaerobic bacteria. Some inhibition due to antibi prophylaxis given to patient just before hip arthroplasty could have negatively influence the results. This study stresses the importance of a rapid seeding of bacterial samples to improve bacterial identification. Procedures should be in place to transfer rapidly samples to the lab and process them immediately

The purpose of this study was to evaluate mortality following delay to surgery in hip fractures in the province of Ontario. All patients undergoing a surgical procedure for a hip fracture between 1993 and 1999 were identified using administrative databases. For every day that surgery was delayed, the adjusted odds of in-hospital mortality increased by a factor of 1.12 times (95%CI), with similar results at three months and one year. A significant relationship exists between delay to surgery and mortality in elderly hip fracture patients. Every effort should be made to avoid non-medical delays in providing operative treatment for hip fractures. To evaluate mortality following delay to surgery in hip fractures in the province of Ontario. A significant relationship exists between delay to surgery and mortality in elderly hip fracture patients. Every effort should be made to avoid non-medical delays in providing operative treatment for patients with fractured hips. This finding will have far reaching implications for the allocation of health resources in the future. All patients undergoing a surgical procedure for a hip fracture between 1993 and 1999 in the Province of Ontario were identified using administrative databases and the provincial mortality database. Multivariable logistic regression models were used to adjust for age, gender, medical comorbidity, type of hip fracture, and teaching status of the treating hospital. For every day that surgery was delayed, the adjusted odds of in-hospital mortality increased by a factor of 1.12 times (95% CI). The adjusted odds of in-hospital mortality increased as the delay to surgery lengthened from a factor of 1.2 [95% CI] with a one day delay to a factor of 1.5 [95% CI] for a delay over two days as compared with patients operated within twenty-four hours. Similar relationships were observed at three months and one year. Even when considering only healthy patients, < seventy years old with no comorbid conditions, the relationship between mortality and surgical delay remained significant (p < 0.0001), suggesting that surgical delay was unlikely to be caused by patient factors alone

This study aimed to ascertain the effect of operative delay on mortality of patients with hip fractures excluding those delayed for medical reasons. In our unit, patients with hip fractures (fractures of the femoral neck and trochanteric zone) have surgery on trauma operating lists shared with plastic surgery emergencies. They are not specifically prioritised and are operated on in order of admission. In a 6-month period, 221 consecutive patients over the age of 65 were planned for surgical treatment of their hip fracture in our unit. 16 patients had surgery delayed for medical reasons and were excluded from further analysis. In a further 9 patients it was not possible to confirm the exact delay to theatre from records and these were also excluded. This left 196 patients in whom it was possible to relate in-hospital and 90-day mortality to surgical delay. These data demonstrate a significant trend towards increasing mortality with increasing delay (χ. 2. -test for trend: p = 0. 0015 (in-hospital) and p = 0. 0021 (90-day)). Comparison of mortality between those delayed 2 days or less (164 patients) and those delayed more than 2 days (32 patients) was also highly significant (Fisher’s exact test: p = 0. 0008 (in-hospital) and p = 0. 0004 (90-day)). We conclude that delays to surgery in patients with hip fractures, particularly beyond 2 calendar days, result in unacceptably high mortality. Practice should be modified to ensure these patients receive greater priority for theatre time

The purpose of this study was to evaluate mortality following delay to surgery in hip fractures in the province of Ontario. All patients undergoing a surgical procedure for a hip fracture between 1993 and 1999 were identified using administrative databases. For every day that surgery was delayed, the adjusted odds of in-hospital mortality increased by a factor of 1.12 times (95%CI), with similar results at three months and one year. A significant relationship exists between delay to surgery and mortality in elderly hip fracture patients. Every effort should be made to avoid non-medical delays in providing operative treatment for hip fractures. A significant relationship exists between delay to surgery and mortality in elderly hip fracture patients. Every effort should be made to avoid non-medical delays in providing operative treatment for patients with fractured hips. This finding will have far reaching implications for the allocation of health resources in the future. All patients undergoing a surgical procedure for a hip fracture between 1993 and 1999 in the Province of Ontario were identified using administrative databases and the provincial mortality database. Multivariable logistic regression models were used to adjust for age, gender, medical comorbidity, type of hip fracture, and teaching status of the treating hospital. For every day that surgery was delayed, the adjusted odds of in-hospital mortality increased by a factor of 1.12 times (95% CI). The adjusted odds of in-hospital mortality increased as the delay to surgery lengthened from a factor of 1.2 [95% CI] with a one day delay to a factor of 1.5 [95% CI] for a delay over two days as compared with patients operated within twenty-four hours. Similar relationships were observed at three months and one year. Even when considering only healthy patients, < 70 years old with no comorbid conditions, the relationship between mortality and surgical delay remained significant (p < 0.0001), suggesting that surgical delay was unlikely to be caused by patient factors alone

Purpose: To determine the effect of delay to surgery on functional outcome in patients with operatively-treated acetabular fractures. Method: Two hundred and thirty-two patients with acetabular fractures were identified from a pelvic trauma database. Functional outcome data was assessed using the validated Musculoskeletal Functional Assessment (MFA) and the Short Form 36 (SF-36) surveys in 162 patients. After 1997, functional outcome scores were collected prospectively at 6 months, 1 year and 2 years (or greater) post-operatively. Functional outcome scores, quality of reduction, and risk of complications were modeled as a function of days of delay to surgery via multivariate regression analysis adjusting for age, gender, fracture type, and associated injuries. Results: At 6 months post-operatively, functional outcome scores were significantly worse with increasing delay to surgery. A delay of between 7 and 13 days or 14 or more days decreased the SF-36 physical component (PCS) z-scores by 0.75 (95% CI: −1.41 to −0.09) and 1.5 standard deviations (95% CI: −2.43 to −0.56) respectively. Delay of 14 or more days was associated with a worsening of the lower extremity (Move) subsection of the MFA by 18.6 points (95% CI: 3.3 to 33.8). Delay to surgery was associated with a significantly higher risk of poor reduction among those with available radiographic follow-up (n=67). Delay 14 days or more was associated with a 5 times (95% CI?.04 to 23.99) greater risk of a post operative step or gap over 2 mm. Delay to surgery was associated with an increase in thrombotic complications. In those patients who were diagnosed with a pulmonary embolism(PE) the mean delay was 11.3 days versus 7.3 days for the rest of the cohort (p=0.01). For patients with a deep vein thrombosis (DVT) average delay was 14.1 days versus 7.1 days (p=0.01). Conclusion: Delay to surgery is associated with worsening functional outcome scores after as little as 7 days of delay. After 14 days, functional outcomes deteriorate further and radiographic outcomes are negatively influenced. Increased delay also increases risk of thrombotic events. These conclusions underscore the importance of timely treatment for displaced acetabular fractures

Objectives. The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function. Methods. Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery. Results. In 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months). The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351). Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001). Conclusions. At five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes. Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2