Distal femoral fracture fixation has historically been associated with high rates of reoperation because of mal-union, non-union and implant failure. We hypothesised that recent advances in distal femoral locking plate design and material along with an improved understanding of biomechanical principles would improve outcome. In a 5-year retrospective study utilising electronic patient records and serial radiographs (including recall by letter where there was no radiological evidence of union) we identified a series of 129 distal femoral fractures treated with modern locking plates in 123 patients. The majority were female (80%), elderly (mean 73 years) and infirm (72/123 ASA 3 or more). A consultant performed the operation in 67% of cases. 49% were followed to radiological union, while 25% died within the follow up period. Reoperation rate for implant failure was 4%, with all failures occurring early (within 5 months). Our follow up correlates with the infirm elderly population concerned. Our cohort shares many similarities with hip fracture patients and we propose that this group should receive equal surgical priority and optimum management also be rewarded by enhanced tariffs. Modern locking plates used in combination with the correct biomechanical principles are performing well in our centre.

The “Golden Patient” is suitability worked up to be the first theatre case of the day; the aim being to improve theatre efficiency. A previous audit of theatre activity demonstrated that the average knife to skin time being achieved across 3 daily trauma lists was 10.12. Over 2-months we introduced a Golden Patient Pathway and completed the audit cycle. The pathway involved a checklist to ensure the completion of essential clinical tasks for each designated golden patient. Activities from 74 trauma theatre cases were reviewed. 47 golden patients remained first whilst 27 were deferred for reasons including non-suitability for golden patient status and emergent cases given clinical priority. The average theatre call time was 24 minutes earlier and the average knife-to-skin time was 15 minutes earlier than non-golden patients during the re-audit. However, when compared to the initial audit the knife-to-skin time had only improved by 3 minutes. Reasons effecting theatre efficiency are multifactorial and other organisational changes had occurred between the audits. This study demonstrates that while the Golden Patient Pathway can improve theatre start times it is not the whole solution. Communication, anaesthetic job plans, portering arrangements, equipment storage and theatre staffing also need to be reviewed.