Ankle fractures in the elderly are common and have a mortality rate of 12% within the first year. Treatment is challenging due to osteoporotic bone and patient co-morbidities. Many patients struggle with non-weight-bearing (NWB) and presently there is no consensus in the literature regarding optimum management of these injuries. We hypothesised that early weight-bearing in frail patients, Clinical Frailty scale (CFS) score of 4 or more will reduce morbidity and allow patients to return to their usual place of residence faster without jeopardising clinical outcome. We conducted a retrospective analysis of 80 patients aged over 65 years managed at Fiona Stanley Hospital for ankle fractures between January 2016 and 2018. Patients were divided into two cohorts: 40 patients managed NWB and 40 who were permitted to weight-bear as tolerated (WBAT). Patients were stratified as fit (CFS 1–3) or frail (CFS 4+). Primary outcomes were one-year mortality, return to primary residence at six weeks and complications. Secondary outcomes included length of acute hospital stay and rehab stay. For frail patients, those managed NWB stayed in rehab for 19 days longer (p=0.03) and had 28% more complications (p=0.03). By 6 weeks, fewer patients returned to full weight-bearing (p=0.03) and fewer patients had returned home (p=0.01). For fit patients, there were no significant differences in primary outcomes between NWB and WBAT. Our novel study categorising patients by CSF demonstrates that early mobilisation in frail patients results in improved outcomes. Currently there is no formal treatment protocol for the management of ankle fractures in the elderly, and we hope that our proposed algorithm will assist surgeons at our institution and elsewhere. Our study suggests that WBAT may benefit frail patients. We propose a protocol to assist in the management of geriatric ankle fracture patients based on clinical frailty scores

Aims. Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic. Methods. A vacated private elective surgical centre was repurposed to facilitate a two-site, ‘COVID’ and ‘COVID-free’, hip fracture service. Patients were screened for COVID-19 infection and either kept at our ‘COVID’ site or transferred to our ‘COVID-free’ site. We collected data for 30 days on patient demographics, Clinical Frailty Scale (CFS), Nottingham Hip Fracture Scores (NHFS), time to surgery, COVID-19 status, mortality, and length of stay (LOS). Results. In all, 47 hip fracture patients presented to our service: 12 were admitted to the ‘COVID’ site and 35 to the ‘COVID-free’ site. The ‘COVID’ site cohort were older (mean 86.8 vs 78.5 years, p = 0.0427) and with poorer CFS (p = 0.0147) and NHFS (p = 0.0023) scores. At the ‘COVID-free’ site, mean time to surgery was less (29.8 vs 52.8 hours, p = 0.0146), and mean LOS seemed shorter (8.7 vs 12.6 days, p = 0.0592). No patients tested positive for COVID-19 infection while at the ‘COVID-free’ site. We redirected 74% of our admissions from the base ‘COVID’ site and created 304 inpatient days’ capacity for medical COVID patients. Conclusion. Acquisition of unused elective orthopaedic capacity from the private sector facilitated a two-site trauma service. Patients were treated expeditiously, while successfully achieving strict infection control. We achieved significant gains in medical bed capacity in response to the COVID-19 demand. The authors propose the repurposing of unused elective operating facilities for a two-site ‘COVID’ and ‘COVID-free’ model as a safe and effective way of managing hip fracture patients during the pandemic. Cite this article: Bone Joint Open 2020;1-6:190–197