Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities.Abstract
Healthcare workers have had to make rapid and drastic adjustments to their practice in response to the COVID-19 pandemic. This work describes the effect on their physical, mental, financial and family well-being and assesses the support provided by their institutions. An online survey was distributed through medical organisations, social media platforms and collaborators to staff based in an operating theatre environment.Abstract
Background
Methods
Adhesive capsulitis is a common condition causing painful limitation of shoulder movements. Hydrodistension is one of the techniques, is well recognised and has shown good outcomes. However, the results of hydro distension release in secondary adhesive capsulitis are not clear. This is a retrospective study on patients undergoing hydro distension release. Patients who had any surgical intervention were classed as secondary whilst the rest were included in the primary group. The hydro distension is a standard technique where in the senior author locates the gleno humeral joint using radio opaque dye, followed by injection of 20 mls 0.5% L-bupivacaine and 80 mg of Triamcinolone, this is followed by use of 60 mls saline to perform the hydro distension.Introduction
Patients and Methods
To see if minor upper limb surgery procedures like CTR, Trigger release, Joint injections are safe for a remote telephonic review by specialist nurse. This arrangement was to help maintain our current agreed departmental New to Follow up ratio of 1:1.56 and also to improve access to specialist clinics. This was a prospective study. Patients undergoing minor procedures were informed about the remote follow up arrangements when placed on waiting list and on the day of surgery. Patients were assured access to clinic up to 3 months after procedure. A specialist nurse undertook a telephone consultation at 2 and 6 weeks using a proforma provided by the Consultant.Aim
Methods
A recent meta-analysis published in the British Medical Journal suggested an increased risk of infection, but none of the studies were large enough to reach statistical significance. A prospective, randomised trial was designed at our institution to investigate the wound healing and complications related to surgery following fracture neck of femur in the elderly. The primary aim was to compare the wound problems and infection following two different methods of skin closure: Subcuticular monocryl suture to metal clips for closure of skin. The secondary aim was to look at the duration of surgery after both types of closure. We received ethical approval for this study. We screened and recruited all eligible patients admitted with acute hip fracture undergoing hemi-arthroplasty or dynamic hip screw. We recruited 541 patients in the study over the period of 3.5 years at our institution.Introduction
Objectives
We wished to assess the usefulness of Inspace balloon arthroplasty (IBA), in our Upper limb unit by regular patient reviews prospectively. This prospective study was started adhering to local approval process. Patients were identified in routine clinical practice by three upper limb consultants presenting with pain and disability and diagnosis of cuff tear was established clinically and on MRI. The patients were explained of ‘available’ treatment options and an information leaflet about balloon arthroplasty provided. Patients were seen in 4 weeks, in a dedicated clinic to find out their willingness to participate. Consultant shoulder surgeons carried out all Balloon arthroplasties and where the cuff was reparable or contraindications identified were excluded from study. All the patients were reviewed by an independent clinician pre-operatively and post operatively using the assessment tools of Oxford Shoulder Scores (OSS), SF12 and VAS at 6 weeks, followed by 3, 6, 12 months and annually after. We performed a total of 32 IBA procedures. At the latest follow-up we identified that 24 patients have completed 2 years post procedure. Of these patients 1 deceased after 6 months, 3 were lost to follow up one each at 6, 12 and 24 months. Three were revised to reverse TSA. The OSS reflects that the positive difference of 10 in the average scores (24 pre-operative versus 34 at 2 years) noted at one year follow up were maintained at 2 years. Similar observations made analysing at 12 months and 2 years scores for the VAS pain scores of 3 at 2 years compared to pre-operative score of 6 and so were improvements in both physical & mental components of SF12. Our study observes that the IBA provides a sustainable pain relief and functional improvements over 2 years and may be a suitable alternative in physiologically compromised patients with irreparable RCT.
The MHRA guidelines for metal on metal (MOM) suggest cobalt and chromium levels of more than 7ppb as potential for soft tissue reaction. However, in some patients soft tissue reaction is seen even in the presence of normal serum metal ions levels. A prospective review of all patients who had metal-on-metal hip arthroplasty was done. Patients who had both serum metal ion levels and MARS MRI scan were included in this study.Introduction
Methods
One of the disadvantages of lateral decubitus position during arthroscopic rotator cuff repair is the difficulty to control arm rotation intraoperatively making it necessary to create additional portals for anchor placement or an additional scrubbed assistant to control arm rotation. We describe the use of commercially available TRIMANO® support arm from Arthrex as an easy device for secure positioning during arthroscopic rotator cuff repair in lateral decubitus position. Though initially marketed to be used for shoulder arthroplasties performed in beach chair position, the senior author has used TRIMANO® to perform arthroscopic rotator cuff repair in lateral decubitus position. The device is easily connected to the operating table side rail while the affected side forearm of the patient is placed in a disposable sterile foam arm holder and attached to the TRIMANO® arm. The “Click and Move” system of the TRIMANO® allows freedom to move the arm in any direction and also provides traction to distract the joint if needed.Introduction
Methods & Technique
Accurate implant size estimation for internal fixation of long bone fractures can reduce intra-operative errors, operative time and radiation exposure. With the advent of pre-packed sterile implants, the exponential increase in the number of internal fixation devices and the lack of standard templates for them on PACS systems, templating has become increasingly difficult. This often results in the opening up of wrong implants leading to increased costs both in terms of increased operative time and additional implants. We describe a technique to determine implant size preoperatively using sterile implant boxes. Post anaesthesia and positioning, the pre packed implant box of approximate size is placed over the limb across the fracture site. An X-ray is then taken using the C-arm. In case of a plate, the number of holes desired on either side of the fracture, the shape of the implant and planned placement of screws are seen. Different implant boxes with the contained implant are placed and once the most appropriate implant for the particular fracture is reached, the box is opened and implant is kept ready for insertion. This technique has been found to be accurate, easy, reproducible and effective for estimating the implant size thereby decreasing the chances of opening wrong implants and saving the intra operative time substantially.
To determine the benefit of dissolvable Balloon Arthroplasy in managing patients with massive irreparable rotator cuff tears (RCT). This is prospective pilot study carried out adhering to the local approval process. Patients having massive cuff tear with pain or functional limitation were seen by consultants and MRI confirmed the diagnosis. The patients were explained of ‘all available’ treatment options and information leaflet about the new procedure balloon arthroplasty, provided. Patients were seen after 4 weeks in a dedicated clinic to find out if they were willing to participate. Patients were seen by a physiotherapist pre and post-operatively at 6 weeks then at 3, 6 and 12months in addition to medical follow-ups, using VAS, Oxford Shoulder, Constant and SF36 scores. All procedures were carried out by consultant shoulder surgeons and where the cuff was reparable or contraindications identified were excluded.Aim
Methods
Revision surgery for a failed metal on metal (MoM) hip arthroplasty is often unpredictable and challenging due to associated massive soft tissue and bony lesions. We present the analysis and early outcomes of revision surgery in failed MoM hip arthroplasties at our institution. We have retrospectively analysed the findings and outcomes of revision surgery in 61 failed MoM hip arthroplasties performed between 2009 and 2014. These patients were identified in the special MoM hip surveillance pathway. All these patients underwent clinical assessment and relevant investigations. Intra-operative and histopathological findings were analysed.Background
Methods
The wrist arthroscopy has been performed since 1979. With the advances in technology and surgical expertise, wrist arthroscopy has become third commonest procedure after knee and shoulder joint. Wrist arthroscopy has become a gold standard for diagnosing TFCC pathologies and other intercarpal disorders. Our aim was to compare the clinical, MRI and arthroscopic findings while treating various wrist pathologies. In retrospective trial, 30 patients (19 male and 11 female) with clinical evidence of wrist lesions were evaluated with MRI followed by wrist arthroscopy. The mean age of the patients at the time of outpatient appointment was 44 years with an average waiting time of 6.6 months. Inclusion criteria: all patients undergoing wrist surgery. Exclusion criteria: septic arthritis, acute distal radius fractures. Kappa analysis was used to compare the three methods of wrist pathology assessment. The total 30 patients were assessed for clinical findings, MRI report and corresponding arthroscopic findings.Introduction
Materials/Method
The carpometacarpal joint of the thumb is one of the most common locations of degenerative arthritis. Surgical options include trapezio-metacarpal fusion, replacement or resection arthroplasty with or without interposition. We report the medium term results of a Modified Thompson's suspensionplasty. The radial half of the APL tendon was looped around the FCR tendon to create the suspension. The remainder of the tendon is then used for interposition. We carried out a retrospective review of 50 patients (67 hands) who underwent this procedure from January 1999 to December 2005. There were 41 female (52 hands) and 9 male (15 hands). The average age at the time of surgery was 62 years (range 41 years – 79 years). The average follow up was 5.33 years (1-9 yrs). 22 patients also had a concurrent second procedure to the same thumb and a further three had a third procedure. The average PRWHE score was 25 (0 – 80) and the average DASH score was 40 (24 – 100) There were eight complications which included four persistent radial sided wrist pain. Two of these underwent tenotomy of FCR, whilst two responded to conservative measures. Two patients had symptoms related to scapho-trapezoid arthritis, which responded to an injection. One patient had superficial infection which settled with oral antibiotics, whilst another patient had early chronic regional pain syndrome. Overall the satisfaction rate was 90% with 48 patients (96%) willing to undergo the same procedure again. We conclude that the modified Thompson's suspensionplasty gives excellent medium term results.
Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery. There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months. There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off. MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP.
To assess the influence of posterior slope on Knee flexion and function in Asian and Caucasian populations. We have conducted a prospective comparative study of 109 Asian and Caucasian posterior tibial slopes. All data has been collected prospectively and includes personal data (height, weight, tibial measurements), ASA grading, knees scores and range of movement. Analysis was performed for the whole group and comparisons were made between the two sets of patients. Minimum follow-up was two years.Aim
Material & methods
Knee warmth is a common clinical observation following total knee arthroplasty (TKA). This can cause concern that infection is present. The purpose of our study was to establish the pattern of knee skin temperature following uncomplicated TKA. It was a prospective study carried out between 2001 and 2004. A pocket digital surface thermometer was used. A preliminary study established that the best site to measure knee skin temperature was superomedial to the patella and the best time was 12 noon. Patients with an increased risk of infection and those with a contralateral knee pathology or a previous surgery were excluded. Forty-eight patients fulfilled the inclusion criteria and consented to participate; the skin temperature of operated and contralateral knees was measured pre-operatively and daily during the first six weeks post-operatively. Measurements were also taken at 3, 6, 12 and 24 months following surgery. During the course of the study, patients developing complications of the operated knee or any pathology of the contralateral knee were excluded. Thirty-two patients completed the main study. Following surgery, systemic and both knees temperatures increased. Whereas systemic and contralateral knee temperatures settled within one week, the operated knee temperature took a longer time. The difference in temperature between the two knees had a mean value of +2.9°C at 7 days. This mean value decreased to +1.6°C at 6 weeks, +1.3°C at 3 months, +0.9°C at 6 months +0.3°C at 12 months and +0.04°C at 24 months. Following uncomplicated TKA, the operated knee skin temperature increases compared to the contralateral knee. This increase peaks at day 3 and diminishes slowly over several months; however, it remains statistically significant up to 6 months. These results correlate with the findings of previous studies that showed a prolonged elevation of inflammatory markers.
We have conducted a case controlled study on a novel cementing technique and compared the results with published optimum levels.
In order to achieve optimum cement penetration we recommend that attention is paid to good pressurization and cement penetration and describe our technique for doing this.
We identified patients with a poor outcome by examining cases where nerve conduction studies had been repeated after surgery. 168 patients were identified in whom two sets of tests had been performed. 28 were excluded as either they had no pre-operative studies or had insufficient clinical information. Our study group was 140 patients (174 hands) in whom NCS had been performed before and after surgery, with adequate clinical information. Information on the clinical outcome was obtained from postal questionnaires and from hospital records. A proportion of the hands in which two tests had been performed turned out to have been retested because of presentation with symptoms in the other hand, after a satisfactory outcome from surgery on the first side. This accounted for 44 of the 174 hands, and these were used as control group. 130 hands in 92 patients were identified as having a poor outcome from surgery. Of these, 39 underwent a further operation; two went on to a third procedure. Logistic Regression Analysis was used to analyze the data (Stastica). There was a trend for the poor results to be more common in the elderly, but age was not a statistically significant factor, (p<
0.36). The good results were found mainly in grades 2 to 5 and this was statistically significant, (p<
0.01). A poorer outcome was seen grouped in grades 0, 1, 2 and 6 and this was statistically significant. (p<
0.01). The NCS have been validated, are reproducible and cost about £15 per study. In the group with good outcome, the grade of severity of NCS improved or remained unchanged in the majority. Of the 39 re-explorations, 17 were found to have incomplete division of the ligament. Of these, 10 showed clinical improvement after re-operation. Of the 22 with no evidence of incomplete division, 7 were improved, 10 had persistent symptoms and 5 were worse after revision surgery. We believe that pre-operative NCS are helpful for two reasons: Firstly, they provide as a baseline for comparison if the patient has unsatisfactory result following decompression. Secondly, we have shown that they are of prognostic value.
The pathogenesis of osteolysis in failed total hip arthroplasty is not fully understood. The purpose of this study is to identify CD4+CD25+ Regulatory T cells in periprosthetic tissues in failed total hip replacements secondary to osteolysis. Intra-operative tissue samples and peripheral blood were collected from patients undergoing revision total hip arthroplasty surgery. Regulatory T cells were present in the tissues, and significantly increased in the peripheral blood in patients with failed total hips compared to normal controls. Further characterization of these regulatory T cells are warranted as they may play a role in osteolysis in loose total hip replacements. Osteolysis remains the most common complication following total joint arthroplasty. To date, no authors have investigated the role of CD4+CD25+ regulatory T cells (TREG) participating in the osteolytic pathogenesis. The purpose of this study is to quantitate the presence of TREG cells in periprosthetic tissues in failed total hip replacements secondary to osteolysis. Fifteen consecutive patients booked for revision total hip arthroplasty secondary to osteolysis were included. Tissue samples were collected: peripheral blood (PB), synovial fluid (SF), synovial tissue (ST), and interface tissue (IT) between the failed component and the bone defect. Total lymphocytes were isolated and analyzed using fluorescent-tagged antibody cell sorting (FACS) for the presence of TREG cells. Frozen sections of ST and IT were analyzed with immunohistochemistry for TREG cells. TREG cells were significantly upregulated (p<
0.01) in the PB (68%) of revision hip patients compared to normal controls PB (44%). In the synovial tissue (ST) and interface tissue (IT), 57% of the lymphocytes isolated were TREG cells. The presence of TREG cells in the ST and IT were confirmed with immunohistochemistry. TREG cells are upregulated in the peripheral blood of patients with failed total hips secondary to osteolysis. The TREG cells are also present in the synovial tissue and interface tissue. Evidence for involvement of regulatory T cells contribute to our understanding of this complex biologic response to artificial wear particles. Functional studies of these TREG cells are warranted as they are upregulated in patients with loose total hip replacements.
Twenty-two patients who underwent thirty-four Kellers’ excision arthroplasty were followed up at an average of thirty-five months. They were assessed using AFAOS, satisfaction and radiological evaluation. The average hallux score was eighty- five (fifty-two to one hundred) while the average lesser toe score was ninety- two (seventy-five to one hundred). The average pain score was thirty- six (twenty to forty) for the hallux and thirty-eight for the lesser toes (twenty to forty). 23/34(68%) had good to excellent, 6/34 (18%) had fair and 5/34(14%) had poor results. The great toe was moderately short, but most patients do not seem to mind this. 91% patients were satisfied with the results. We undertook a retrospective study of Kellers’ excision arthroplasty done over the last seven years to assess the medium term results. Twenty-two patients who underwent thirty- four Kellers’ excision arthroplasty were followed up at an average of thirty-five months. They were followed up using the AFAOS, patient satisfaction and radiological evaluation. The average age at the time of surgery was 67.4 years. There were seventeen females (twenty-five feet) and five males (nine feet). All patients underwent bunionectomy along with excision of proximal third of the proximal phalanx. Of these twenty underwent K wire stablization of the hallux following excision. The average hallux score was eighty- five (range sixty-two to one hundred) while the average lesser toe score was ninety- two (range seventy-five to one hundred). The average pain score was thirty- six (range twenty to forty) for the hallux and thirty-eight for the lesser toes (twenty to forty). 23/34 (68%) had good to excellent, 6/34 (18%) had fair and 5/34(14%) had poor results. The average correction of the hallux valgus was 9o. The average IMT was 25o preoperatively and 18o postoperatively. The average shortening was 7 mm. Complications included two cases of transfer metatarsalgia and two cases of clawing of the lesser toes. One patient developed abscess which settled after incision and drainage. Thirty-one out of thirty-four patients were satis-fied with the final outcome and thirty out of thirty-four patients would have the operation on the other feet. The great toe is moderately short, but most patients do not seem to mind this. 91% patients were satisfied with the results.
T cells have been implicated in the pathogenesis of osteolysis. The goal of this study was to compare the ratios of CD4+ T cell populations in total hip arthroplasty (THA) patients with and without osteolysis. We found no significant differences in the frequency of peripheral blood CD4+CD25+ regulatory and effector T cells, serum IL-10 and TGF-β concentrations, and immuno-suppressive ability of regulatory T cells from patients with osteoarthritis prior to THA, and THA patients with and without radiographic evidence of osteolysis. CD4+ T cells are critical in regulating immune-mediated conditions. This study compared the frequency of CD4+ T cell subpopulations in the peripheral blood of patients with and without osteolysis following total hip arthroplasty (THA). Numbers of CD4+CD25hi regulatory T cells, CD4+CD25moderate effector T cells, and CD4+CD25+ T cells in the peripheral blood of thirty patients with osteoarthritis prior to primary THA, thirty patients with asymptomatic THAs and no radiographic evidence of osteolysis, nineteen patients with asymptomatic THAs with radiographic evidence of early osteolysis (not requiring revision surgery) and nine patients scheduled for revision THA for osteolysis were determined by flow cytometry. Serum IL-10 and TGF-β levels were measured using ELISA kits. Results were compared by t-test and rank sum test. CD4+ CD25hi regulatory T cells and CD4+ CD25neg T cells were isolated from blood using a MACS cell isolation kit, co-cultured for three days, and T cell proliferation determined by [3H]-thy-midine uptake. The frequency of CD4+CD25hi regulatory T cells, CD4+CD25moderate effector T cells, and CD4+CD25+ T cells were similar in each study group. Regulatory T cells from patients with and without osteolysis had a normal functional ability to inhibit CD4+ T cell proliferation. Serum levels of the regulatory T cell-derived cytokines IL-10 and TGF-β were also comparable between groups. Our data suggests that CD4+ T cell immune responses are normal in THA regardless of the level of osteolysis, in contrast to previous studies that have implicated T cell hypersensitivity in the pathogenesis of osteolysis surrounding THA.
We undertook the current study to analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability. Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two and the average follow up was fifty-eight months. There were sixteen females and fifty-eight males. All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. Ten had a recurrence of instability. Of these two had significant trauma. Of the remaining, six were in the arthroscopic group and two in the open procedure group. Analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability. Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two years (range nineteen to forty-seven). There were sixteen females and fifty-eight males. The average follow up was fifty-eight months (range seven to eighty-three). All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. The arthroscopic procedure involved two Suretac II labral reattachment and capsular shrinkage using electrocautery. The open procedure involved a Bristow/Latarjet procedure using a delto-pectoral approach and reattachment of coracoid process using a single malleolar screw. Ten patients had a recurrence of instability. Of these two had significant trauma, one each group. Of the remaining eight, six were in the arthroscopic group and two in the open procedure group. In the arthroscopic recurrence group, three had a large Hill Sach’s lesion and one a large Bankart Lesion. In the open procedure group, both had a large Hill Sach’s and Bankart’s lesion. This gave a recurrence rate of 12.7% in the arthroscopic group and 7.4% in the open group. A large Hill-Sach lesion >
2mm is a contra-indication to arthroscopic repair and the optimum stabilisation procedure is an open repair (Bristow/Laterjet). Without a significant Hill-Sach’s lesion an arthroscopic Suretac II labral re-attachment is an effective way of achieving stability. Those who have a large Hill-Sach and significant Bankart’s lesion may need a combination of Bankart’s repair plus an extra-articular procedure like a Bristow/Laterjet procedure.
Age more than 65 years (p value 0.006), comminuted distal radius fracture [A3 or C3 in AO classification] (p value 0.049) and associated ulnar fracture (p value 0.013) were the variables found to have statistically significant correlation with poor radiological outcome.
All patients were operated between the ages of 6–9 months. A modified Turco’s technique was used. A longer incision extending to the lateral border of tendo-achilles was used. The abductor hallucis was completely excised. No K wire was used for holding the correction. All children were left in plaster till they started walking. A modified splint and correction shoes were used in the post-operative period. There were no wound problems in any cases, either at the time of wound closure or later on.
All supracondylar humeral fractures managed with closed or open reduction and pin fixation at the Hospital for Sick Children between 1995 and 2002 were retrospectively reviewed. Time from injury to treatment, post reduction complications and need for open reduction were recorded. Fractures treated ≥ 8 hours from injury were considered in the early treatment group while >
8 hours were considered in the late treatment group. Fractures presenting with a cold hand (four patients) were taken to the operating room as quickly as possible and were excluded from the study. There were 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. The early treatment group consisted of 230 patients with two compartment syndromes, six ulnar-, one superficial radial-, one median- and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions and one re-manipulation was required for loss of reduction. The late treatment group consisted of 342 patients with six ulnar-, three median-, one radial nerve palsy and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions and re-manipulation was required in one patient. All nerve palsies recovered post-operatively. Conclusion: There was no significant difference in the proportion of complications between the early and late treatment group, but the most severe complication, the development of a compartment syndrome was only seen in the early group. Delayed treatment of supracondylar humeral fractures seems to be safe in a large number of patients, and in fact, most of our patients were treated more than eight hours from the injury. Early operation of fractures not associated with a neurovascular compromise also does not seem to reduce the complication rate. Nevertheless the decision when to operate needs to be decided for each patient individually.