Introduction. Neck of femur (NoF) fractures have an inherent 6.5% 30-day mortality as per National hip fracture database(2019). Several studies have demonstrated a higher mortality rate in covid positive NoFs but have been unable to demonstrate whether there are risk factors that contribute to the risk of mortality in this patient group or whether COVID is solely responsible for the higher mortality. Aims. To assess risk factors that are concurrently present in a fracture NoF cohort that may contribute to higher mortality in COVID positive patients. Methods. A cross sectional, retrospective study was performed for a period of 1 year starting from 1st March 2020. All surgically treated neck of femur fracture patients having an isolated intra/extracapsular fracture were included in the study. Data fields recorded- patient demographics, date and time of admission, ward discharge, surgery, mode of surgery (fixation/arthroplasty), prehospital AMTS score, residential status and mobility, ASA grade as per anaesthetist's records, date of death (if deceased), cause of death (as per death certificate/ postmortem / coroner's report). Analysis of mortality was carried out by creating a matched comparison group for each risk factor as well as some combinations. Results. 344 patients were surgically treated for a neck of femur fracture in our DGH during the period of 1st March 2020 to 28th February 2021. 46 patients did not receive a COVID swab (reasons unknown) and were excluded from the study. 35 patients had a COVID-19 RT PCR positive test during their hospital stay and 264 patients remained negative. There were 12 deaths in COVID positive patients (34%) and 53 deaths in COVID negative patients (20%) within the time frame of the study. For each risk factor matched group COVID was seen to confer higher mortality in general. There was no mortality in ASA 1 or 2 patients. Mortality rates in matched groups for age and ASA revealed 23.8% mortality in COVID positive as opposed to 17.3% in COVID negative for ASA 3 and 33.3% mortality in COVID positive vs. 28% in ASA 4. 11 out of the 12 COVID positive patients who died had an AMTS score >6. No correlation was seen between COVID positive deaths and preinjury residential status, type of fracture or surgery offered, or preinjury mobility. The average length of hospital stay was much higher for COVID positive patients (19.5days) as compared to 9.5 days for COVID negative patients. Conclusion. Matched group analysis show that there is a 37.5% increase in COVID positive neck of femur fracture mortality in ASA 3 patients, the same number falls to 17.8% for ASA 4 patients. These figures are much lower compared to other studies in the UK. There is a need to understand the real cause of death in this subset and to improve death certification so that we can differentiate between patients whose mortality is ‘due to’ or ‘With’ COVID

Aims. Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in a motor impairment affecting the upper limbs more than the lower limbs, with occasional sensory impairment and urinary retention seen. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study is to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Patients and Methods. Patients ≥18 years with traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and injury, management and outcome data was collected. Statistical analysis was performed to assess mortality and between group differences. Results. 65 patients were identified (66.2% male, mean age 63.9 years). At five-years follow-up, 32.3% (n=21) of CCS patients were dead. 6 (9.2%) patients had died within 31 days of their injury. 69.2% (n=45) of patients were managed conservatively and there was no significant difference (p=0.062) in age between conservatively and surgically managed patients. Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively compared to those managed surgically (log rank test, p=0.819). However, there was a significant difference (p=0.001) in mortality between the different age groups (<50 years vs 50–70 years vs >70 years). At five-years follow up, 55.6% of the patient group aged >70 years at time of injury were dead. Respiratory failure was the most common cause of death (n=9, 42.9%). Conclusion. Almost one third of patients with traumatic CCS in Wales were dead at five years following their injury. Management type did not significantly affect mortality, however age at time of injury did. Further work assessing the long-term functional outcomes of surviving patients is needed, to allow more reliable prognostic information and functional recovery predictions to be given

Aims. This retrospective study aimed to determine the causes of in-hospital death after Neck of Femur (NOF) fracture in Southampton General Hospital (SGH) over a 6 year period, comparing the clinical cause of death with findings at post-mortem. A previous study showed discrepancies between pre-mortem clinical diagnosis and autopsy findings after in-hospital deaths in SGH. Methods. The study included all patients who died in SGH after NOF fracture from 2007–2013. Case notes were reviewed to determine the pre-mortem clinical diagnosis and compared with the autopsy findings to analyse major and minor discrepancies. Data were also analysed from the period 1997–2003 in order to compare the causes of death. Results. 43 cases were referred for autopsy after NOF fracture during the 6 year study period, of which 39 cases (90.1%) were available for analysis. There was complete agreement between pre-mortem clinical diagnosis and autopsy findings in 64.1% of cases. Major discrepancies were found in 35.9% of cases and minor discrepancies in 23.1% of cases. Causes of death due to bronchopneumonia and pulmonary embolism had decreased significantly during the recent 6 year period when compared with the previous study period. No pulmonary emboli were identified as the primary causes of death between 2007 and 2013. Conclusion. Deaths due to pulmonary emboli after NOF have declined significantly. The reasons for this are unclear and are the subject of an ongoing study which will be discussed. Discrepancies between pre- and post-mortem diagnoses highlight the importance of autopsy findings. The current study revealed a similar rate of major discrepancies compared to the previous study

The goal of this study was to identify the effect of mismatches in the subchondral bone surface at the native:graft interface on cartilage tissue deformation in human patellar osteochondral allografts (OCA). Hypothesis: large mismatches in the subchondral bone surface will result in higher stresses in the overlying and surrounding cartilage, potentially increasing the risk of graft failure. Nano-CT scans of ten 16mm diameter cadaveric patellar OCA transplants were used to develop simplified and 3D finite element (FE) models to quantify the effect of mismatches in the subchondral bone surface. The simplified model consisted of a cylindrical plug with a 16 mm diameter (graft) and a washer with a 16 mm inner diameter and 36 mm outer diameter (surrounding native cartilage). The thickness of the graft cartilage was varied from 0.33x the thickness of native cartilage (proud graft subchondral bone) to 3x the thickness of native cartilage (sunken graft subchondral bone; Fig. 1). The thickness of the native cartilage was set to 2 mm. The surface of the cartilage in the graft was matched to the surrounding native cartilage. A 1 MPa pressure was applied to the fixed patellar cartilage surface. Scans were segmented using Dragonfly and meshed using HyperMesh. FE simulations were conducted in Abaqus 2019. The simplified model demonstrated that a high stress region occurred in the cartilage at the sharp bony edge between the graft and native subchondral bone, localized to the region with thinner cartilage. A 20% increase in applied pressure occurs up to 50μm away from the graft edge (primarily in the graft cartilage) for grafts with proud subchondral bone but varies little based on the graft cartilage thickness. For grafts with sunken subchondral bone, the size of the high stress region decreases as the difference between graft cartilage and native cartilage thickness decreases (Fig. 2-4), with a 200 μm high stress region occurring when graft cartilage was 3x thicker than native cartilage (i.e., greater graft cartilage thickness produces larger areas of stress in the surrounding native cartilage). The 3D models reproduced the key features demonstrated in the simplified model. Larger differences between native and graft cartilage thickness cause larger high stress regions. Differences between the 3D and simplified models are caused by heterogeneous cartilage surface curvature and thickness. Simplified and 3D FE analysis confirmed our hypothesis that greater cartilage thickness mismatches resulted in higher cartilage stresses for sunken subchondral bone. Unexpectedly, cartilage stresses were independent of the cartilage thickness mismatch for proud subchondral bone. These FE findings did not account for tissue remodeling, patient variability in tissue mechanical properties, or complex tissue loading. In vivo experiments with full-thickness strain measurements should be conducted to confirm these findings. Mismatches in the subchondral bone can therefore produce stress increases large enough to cause local chondrocyte death near the subchondral surface. These stress increases can be reduced by (a) reducing the difference in thickness between graft and native cartilage or (b) using a graft with cartilage that is thinner than the native cartilage. For any figures or tables, please contact the authors directly

Distracted driving is now the number one cause of death among teenagers in the United States of America according to the National Highway Traffic Safety Administration. However, the risks and consequences of driving while distracted spans all ages, gender, and ethnicity. The Distractions on the Road: Injury eValuation in Surgery And FracturE Clinics (DRIVSAFE) Study aimed to examine the prevalence of distracted driving among patients attending hospital-based orthopaedic surgery fracture clinics. We further aimed to explore factors associated with distracted driving. In a large, multi-center prospective observational study, we recruited 1378 adult patients with injuries treated across four clinics (Hamilton, Ontario, Toronto, Ontario, Calgary, Alberta, Halifax, Nova Scotia) across Canada. Eligible patients included those who held a valid driver's license and were able to communicate and understand written english. Patients were administered questions about distracted driving. Data were analyzed with descriptive statistics. Patients average age was 45.8 years old (range 16 – 87), 54.3% male, and 44.6% female (1.1% not disclosed). Of 1361 patients, 1358 self-reported distracted driving (99.8%). Common sources of distractions included talking to passengers (98.7%), outer-vehicle distractions (95.5%), eating/drinking (90.4%), music listening/adjusting the radio (97.6%/93.8%), singing (83.2%), accepting phone calls (65.6%) and daydreaming (61.2%). Seventy-nine patients (6.3%), reported having been stopped by police for using a handheld device in the past. Among 113 drivers who disclosed the cause of their injury as a motor vehicle crash (MVC), 20 of them (17%) acknowledged being distracted at the time of the crash. Of the participants surveyed, 729 reported that during their lifetime they had been the driver in a MVC, with 226 (31.1%) acknowledging they were distracted at the time of the crash. Approximately, 1 in 6 participants in this study had a MVC where they reported to be distracted. Despite the overwhelming knowledge that distracted driving is dangerous and the recognition by participants that it can be dangerous, a staggering amount of drivers engage in distracted driving on a fairly routine basis. This study demonstrates an ongoing need for research and driver education to reduce distracted driving and its devastating consequences

Venous thromboembolism (VTE) is the second most common complication and pulmonary embolism (PE) is the fourth most common cause of death after a hip fracture. Despite thromboprophylaxis, deep vein thrombosis (DVT) is detected in up to 45% of hip fracture patients. Thrombelastography (TEG) is a whole-blood, point of care test capable of providing clinicians with a global assessment of the clotting process, from fibrin formation to clot lysis. Maximal amplitude (mA) from TEG analysis is a measure of clot strength. Elevated admission mA values of >65mm and >72mm have been determined to be independent predictors of in-hospital PE. The coagulation index (CI) is calculated based on TEG parameters and defines hypercoagulable state as CI >3. This study aimed to use serial TEG analysis to determine the duration of hypercoagulable state after hip fracture. A prospective cohort of hip fracture patients >50 years of age amenable to surgical treatment (AO 31A1–A3 & 31B1–B3) were enrolled at a Level I trauma centre. Serial TEG analysis (TEG 6S) was performed every 24-hours from admission until 5-days post-operatively and at 2- and 6-week follow-up visits. All patients received a minimum of 28 days of thromboprophylaxis. Descriptive statistics and single sample t-tests were used for comparison of mA to the 65mm threshold. Thirty-five patients (26 female) with a median age of 83 (range = 71–86) years were included. On admission, 31.4% and 82.9% of patients were hypercoagulable based on mA >65mm and CI, respectively. At 2 weeks, all patients remained hypercoagulable, however, mA >72mm showed that 16 patients (47.1%) were at even higher risk for VTE. At 6-weeks, 65.7% and 97.1% of patients were hypercoagulable based on mA >65mm and CI, respectively. When compared with the mA >65mm threshold, patients were hypocoagulable at the time of admission (mA = 62.2 (±6.3), p = 0.011), but became significantly more hypercoagulable at 2-weeks (mA = 71.6 (±2.6), p < 0 .001), followed by continued hypercoagulability at 6-weeks, however not significantly elevated above the 65mm threshold (mA = 66.2 (±3.8), p = 0.058). One patient developed a symptomatic DVT at 2-weeks and had a mA = 72.9 and a CI of 5.9. This is the first study to demonstrate that >50% of hip fracture patients remain hypercoagulable 6 weeks post fracture despite thromboprophylaxis, and there are individual hypercoagulable responses. This is critical, as guidelines only recommend 28 to 35 days of thromboprophylaxis in this high-risk population. Previously determined mA thresholds may be a more sensitive test for risk-stratifying patients' VTE risk than the CI threshold. Additionally, assessing ΔmA using serial TEG may better predict VTE risk

Aim. To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period. Material and methods. Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates. A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible), mechanical prophylaxis (Flo-tron calf garment per-operatively, AV impulse boots until mobile and anti-embolism stockings for 6 weeks), mobilisation within 24 hours and 75mg aspirin for 4 weeks. A case note review was performed to ascertain the causes of death. Where a patient had been referred to the coroner, the coroner's office was contacted for PM results. Results. There were 6,584 cases; the mortality rates at 42 and 90 days were 0.36 and 0.52%. There were no fatal PE's within 42 days of surgery. 2 fatal PE's occurred subsequently at 48 and 57 days (0.03%) The leading causes of death were myocardial infarction and cerebro-vascular accident. Conclusion. Fatal pulmonary embolus following elective TKR with a multi-modal prophylaxis regime is not a significant cause of mortality

STS are rare malignant tumours of mesenchymal origin giving a wide array of histological types and behaviour. Common sites of involvement include the extremities which are of most relevance to orthopaedic surgeons. Like almost all other malignancies, STS become more common with increasing age with median age of 65 years. All patients aged 65 and over with STS of the extremities referred to the NZ Tumour Registry at Middlemore Hospital between 1967 and 2010 were included in the study. Data collected include baseline demographics (age, sex), diagnosis, site, time of referral, definitive treatment, adjuvant therapy, surgical margins (if applicable), local recurrence, survival, and cause of death. Each patient was staged according to AJCC (1997, 5th edition) and Enneking's staging systems. Primary outcomes were measured in terms of 5-year survival alongside with cause of death. A total of 116 patients. 21 upper extremities, 95 lower extremities. Average age of 74 with a 1.2:1 female to male ratio. Stage 1 disease was uncommon, accounting for only 5 cases (4%). 3 patients died within 5 years (1 due to metastatic disease and 2 from non-sarcoma related disease). 2 patients were still alive in 2010 with 1 of them surviving >5yrs. Stage 2 disease was found in 41 patients (35%). Common histologies included malignant fibrous histiocytoma (MFH), liposarcomas, or leiomyosarcomas (LMS). 44% (n=18) had greater than 5-year survival. 20% (n=8) died within 5 years succumbing to metastatic disease. 11 were under 5-yr follow up. Stage 3 disease was found in 48 patients (41%). MFH was by far the most common diagnosis accounting for 63% of patients. 5-year survival 25% (n=12). 5-year mortality 56% (n=27) mainly from advanced disease and metastases. Rest (n=9) are still within 5-yr follow up. Distant metastases at presentation were seen in about 10% of all patients (12 cases) with the most common site of involvement being the lung. 9/13 died of metastatic disease within 5 yrs while others are still within the 5 yr follow up period. STS are most commonly observed in the elderly and prognosis depends on several factors. Management should ideally be carried in a specialised centre with early referral and combined multidisciplinary approach to optimise patient outcome

Lung cancer is the most common cancer diagnosed, the leading cause of cancer-related deaths, and bone metastases occurs in 20–40% of lung cancer patients. They often present symptomatically with pain or skeletal related events (SREs), which are independently associated with decreased survival. Bone modifying agents (BMAs) such as Denosumab or bisphosphonates are routinely used, however no specific guidelines exist from the National Comprehensive Cancer Center or the European Society of Medical Oncologists. Perhaps preventing the formation of guidelines is the lack of a high-quality quantitative synthesis of randomized controlled trial (RCT) data to determine the optimal treatment for the patient important outcomes of 1) Overall survival (OS), 2) Time to SRE, 3) SRE incidence, and 4) Pain Resolution. The objective of this study was to perform the first systematic review and network meta-analysis (NMA) to assess the best BMA for treatment of metastatic lung cancer to bone. We conducted our study in accordance to the PRISMA protocol. We performed a librarian assisted search of MEDLINE, PubMed, EMBASE, and Cochrane Library and Chinese databases including CNKI and Wanfang Data. We included studies that are RCTs reporting outcomes specifically for lung cancer patients treated with a bisphosphonate or Denosumab. Screening, data extraction, risk of bias and GRADE were performed in duplicate. The NMA was performed using a Bayesian probability model with R. Results are reported as relative risks, odds ratios or mean differences, and the I2 value is reported for heterogeneity. We assessed all included articles for risk of bias and applied the novel GRADE framework for NMAs to rate the quality of evidence supporting each outcome. We included 132 RCTs comprising 11,161 patients with skeletal metastases from lung cancer. For OS, denosumab was ranked above zoledronic acid (ZA) and estimated to confer an average of 3.7 months (95%CI: −0.5 – 7.6) increased survival compared to untreated patients. For time to SRE, denosumab was ranked first with an average of 9.1 additional SRE-free months (95%CI: 4.0 – 14.0) compared to untreated patients, while ZA conferred an additional 4.8 SRE-free months (2.4 – 7.0). Patients treated with the combination of Ibandronate and systemic therapy were 2.3 times (95%CI: 1.7 – 3.2) more likely to obtain successful pain resolution, compared to untreated. Meta-regression showed no effect of heterogeneity length of follow-up or pain scales on the observed treatment effects. Heterogeneity in the network was considered moderate for overall survival and time to SRE, mild for SRE incidence, and low for pain resolution. While a generally high risk of bias was observed across studies, whether they were from Western or Chinese databases. The overall GRADE for the evidence underlying our results is High for Pain control and SRE incidence, and Moderate for OS and time to SRE. This study represents the most comprehensive synthesis of the best available evidence guiding pharmacological treatment of bone metastases from lung cancer. Denosumab is ranked above ZA for both overall survival and time to SRE, but both treatments are superior to no treatment. ZA was first among all bisphosphonates assessed for odds of reducing SRE incidence, while the combination of Ibandronate and radionuclide therapy was most effective at significantly reducing pain from metastases. Clinicians and policy makers may use this synthesis of all available RCT data as support for the use of a BMA in MBD for lung cancer

Meningococcal infection is the most common infective cause of death in children and causes significant morbidity in survivors. Patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with a primary diagnosis of meningococcal septicaemia were reviewed. A total of 10 (7.7%) of 130 patients developed orthopaedic complications. Those affected were significantly younger (p < 0.05), remained on PICU for longer (p < 0.001) and boys had a greater risk of developing orthopaedic complications (risk ratio: 3.1; 95% CI: 0.69–14.14). 9 patients required an amputation, 16/22 (72.7%) in the lower limb. Patient requiring amputation had multiple limb involvement. 48 growth plate abnormalities were identified in 8 patients, 39 (81.3%) in the lower limb, most commonly in the distal tibia. This study has identified a high incidence of musculoskeletal morbidity. Close surveillance of these patients is recommended to identify growth arrest before the onset of clinically significant deformity. It identifies a defined population of patients with meningococcal septicaemia using admission to PICU as an entry criterion allowing accurate determination of the incidence and characteristics of the skeletal consequences of this condition

Introduction. Despite the lack of robust evidence, numerous different track and trigger warning systems have been implemented. The MEWS (Modified Early Warning Score system) is one such example, and has not been validated in an emergency traumasetting. A considerable proportion of trauma admissions are elderly patients with co-morbidities. Early recognition of physiological deterioration and prompt action could therefore be lifesaving. Aim. Identify whether the implementation of a MEWS system coupled with an outreach service had resulted in a reduction in the mortality within our unit. Method. Retrospective study. The MEWS was implemented in 3 Trauma and Orthopaedic wards at the Leicester Royal Infirmary in the summer of 2005. The number of emergency trauma inpatient admissions and deaths from January 2002 to December 2009 were obtained. The diagnosis, primary procedures and cause of death, if known, were noted. Comparisons between pre and post MEWS implementation made. Results. 32,149 admissions (55% male; 45% female) with 889 deaths (67% female; 33% male, P< 0.0001.). 61% of admissions were due to proximal femoral fractures. The peak age of death was 71–80 years. A reduction has occurred in the mortality rate post-MEWS implementation in male (1.82 to 1.418; P=0.214), female (4.871 to 3.364; P=0.108) and total deaths (3.215 to 2.294; P=0.092), but this is not significant. Conclusion. Mortality has not reduced since the introduction of MEWS to our trauma unit. In view of the apparent lack of clinical effectiveness of the MEWS/outreach partnership, we question the cost effectiveness of this initiative. Possible reasons may include: failure of the MEWS to be correctly applied; inadequate action once the threshold is triggered; or unsuitability of this tool for this patient population. A better system for identifying and treating trauma patients needs to be developed, which is suited to elderly patients with co-morbidities

There is widespread appreciation amongst orthopaedic surgeons of the importance of thromboprophylaxis. However much of the evidence is based on surrogate outcomes of clinical end-points. This population-based study aims to identify the incidence and trends in venous thromboembolic disease (VTE) following total hip (THR) and knee arthroplasty (TKR) with death or readmission for VTE up to two years following surgery for all patients in Scotland as the primary outcome. We used the Scottish Morbidity Record (SMR01) system to identify all patients undergoing hip or knee arthroplasty over the ten-year period from 1992 to 2001. Patients undergoing cataract surgery over the same period were identified as a control group. Record linkage for all patients to subsequent SMR01 and Registrar General records provided details of further admissions due to DVT or non-fatal PE and deaths within Scotland up to two years after the operation. The cause of death was determined from the Registrar General Records. The incidence of VTE (including fatal pulmonary embolism (PE)) three months following primary THR was 2.27% and primary TKR was 1.79%. The incidence of fatal PE within three months of THR was 0.22% and TKR was 0.15%. The majority of events occurred in the interval from hospital discharge to six weeks after surgery. There was no apparent trend over the period. An apparent reduction in the overall mortality within 365 days of surgery appears to be due to a reduction in the incidence of acute myocardial infarct. The data support the current advice that prophylaxis should be continued for at least six weeks following surgery. Despite increased uptake of prophylaxis regimens and earlier mobilisation, there has been no apparent change in the incidence of symptomatic VTE over the ten-years from 1992 to 2001

Distal radius fractures are common, yet the long-term functional outcome of these patients is unknown. This study investigated the long-term functional outcomes after distal radius fracture (DRF) in adult patients 16–23 years following injury. Secondary aims were to establish morbidity, mortality and function related to pattern of injury and patient demographics. Methods. 622 consented adult patients with a DRF were enrolled in the study. Prospective data was recorded; patient age, mechanism of injury and fracture pattern. Patients were assessed 16–23 years post-injury. 275 patients were deceased. 194 patients were able to complete a Quick Dash (QD) validated upper limb pain and function Patient-Reported Outcome Measure (PROM). Five patients declined follow-up. Socioeconomic status was assessed using the Scottish Index of Multiple Deprivation (SIMD) 2009. Results. The mean age at injury was 41 years for men and 64 for women in the initial cohort. 146 women and 48 men completed final follow-up. The mean age at QD assessment was 57 years for men and 76 for women; mean and median SIMD deciles were 6.7 and 7, respectively, for both genders. The mean QD score was 10.35 for all patients, with no significant gender difference (p=0.63). 85.6% (n=166) reported no or at most, mild limitation. High socioeconomic status, absence of other injuries at DRF and age under 85 years old at follow-up was associated with better long-term function. Early function and pain predicted long-term function; comminution pattern, treatment modality as chosen by surgeon, and early complications did not. Mortality data was analysed for the deceased (n=275). The mean patient survival from DRF to death was 11 years 5 months, with no significant gender difference (p=0.43); survival was predicted by age at injury, post-treatment dorsal angulation and early function. Respiratory, cardiovascular causes and malignancy were the three most common primary causes of death

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

Introduction. Surgical complications are common and most of them are preventable. Up to 70 % of surgical errors originate outside theatre and recent studies have shown that pre-op checklists can reduce such problems. We hypothesized that in our institution outcomes could be improved by introducing a safety checklist. Method. A modified multidisciplinary WHO safety checklist was introduced at our institution on the 1st March 2011. The primary focus was for elective patients admitted in all the units of the division. Prior to that all involved personnel (Consultants in Orthopaedics and Anaesthesia, Registrars in both departments, nursing staff in the wards and theatre and clerical staff) were fully oriented. To further ensure that everyone was familiar with the new checklist the whole month of March 2011 was used as a training month. We prospectively collected data from daily Mortality and Morbidity (MM) meetings by units from 1/1/2011 to 29/2/2011 (2 months). A pre-induction survey was completed by all Registrars. The same survey was given to the same registrars for comparison at the end of the 2 month implementation period in June 2011. Results. Only 77% of registrars acknowledged doing pre-op planning prior to implementation of the check list compared to 87.5% post implementation. There was also an increase from 50 to 71% of those who had heard of the surgical check list pre-implementation compared to post implementation. There were 35 cancellations before and 36 after implementation. However if one breaks them into unavoidable and avoidable groups there was 70% reduction of avoidable cancellations (from 10 to 3 patients). There was a 25% reduction of mortality and a 25% reduction of avoidable morbidity. Discussion. In our study there was significant increase in the percentage of registrars who were doing pre-op planning after the implementation of the modified WHO safety check list. The avoidable theatre case cancellations were significantly reduced. It is very hard to attribute the reduction of mortality in our studies to our checklist as the documented causes of death were unavoidable. Compared to published studies our numbers were relatively small but comparable to the SURPASS study which showed reduction of complications from 27.7 % to 16.7 %. The time for getting acquainted to the safety checklist was also very short (1 month) compared to other published studies. Conclusion. The implementation of the modified WHO safety check list was associated with reduction in cancellations, avoidable morbidity and mortality. It should be regarded as a standard practice for all orthopaedic procedures to decrease complications especially in high operation volume and training centres. NO DISCLOSURES

Introduction. Trauma is the leading cause of death and disability in children. Pelvic fractures although rare, with a reported incidence of one per 100,000 children per year are 2. nd. only to skull fractures with respect to morbidity. The objectives of this study were to improve understanding of paediatric pelvic fractures through a concise review of all aspects of these fractures and associated injuries. Understanding the patterns in which paediatric pelvic fractures and their associated injuries occur and the outcome of treatment is vital to the establishment of effective preventative, diagnostic and therapeutic interventions. Patients and Methods. All children admitted to our unit with a pelvic fracture over the 14-year period from January 1995 to December 2008 were identified. The complete medical records and radiographs of all patients were obtained and reviewed. Data recorded included, age, sex, mechanism of injury, Glasgow Coma Score, Injury Severity Score, fracture type, radiological investigation, length of in-patient stay, length of intensive care unit stay, blood transfusion requirement, associated injuries, management (both orthopaedic and non-orthopaedic), length of follow-up, and outcome. Results. Over the study period thirty-nine children with a pelvic fracture were treated at our institute. The patients ranged in age from 1 to 14 years with a mean age of 8.6. The mean Glasgow coma score at presentation was 13.25 (range 3-15). The mean Injury Severity Score (ISS) was 17.1 (range 4-75). The most common mechanism of injury was a pedestrian being struck by a motor vehicle. A pelvic fracture was evident on the initial plain radiographs of all 39 children. Further radiographic investigation (12 CT's and 1 MRI) of the pelvic injury were undertaken in 13 (33%) of the children. Additional posterior ring fractures were identified in 9. The majority of children (18/39, 46%) sustained a Torode and Zeig type 3 fracture. A total of 32 children (82%) sustained one or more associated injuries. Head injuries accounted for 25% of these. Associated orthopaedic/skeletal injuries consisted of 22 fractures in 18 children accounting for 33% of all associated injuries. Fourteen children required a total of 24 acute surgical procedures, these were divided into orthopadic (n=12) and non-orthopaedic (n=12). The orthopaedic management of the pelvic fracture was non-operative in 37 (94%) of the children. Mean out-pateint clinical follow-up was for 27 months (range 3-85). There was one mortality in this series. Eight children (20%) suffered long term sequale. Conclusion. Pediatric pelvic fractures differ from their adult counterpart in etiology, fracture type, and associated injury pattern. They represent a reliable marker for severe trauma and associated injuries should be sought out in all cases. Injury to other organ systems should prompt early evaluation by the appropriate specialists. Optimal treatment guidelines for paediatric pelvic fractures are not yet fully defined but would seem to favour the management of more skeletally mature adolescents by the same principles used in the adult population

Aims

Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.

Despite improved body armour haemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, goin and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a pre-hospital device capable of preventing pelvic and proximal lower limb haemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure and abdominal girth were recorded. Doppler Ultrasound was used to identify blood flow in the Common Femoral Artery (CFA). The AAT was applied whilst the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, BMI & abdominal girth. This study shows the Abdominal Aortic Tourniquet to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving

Aims

To establish if COVID-19 has worsened outcomes in patients with AO 31 A or B type hip fractures.

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.