Aims. The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods. Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results. The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion. Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients’ health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment. Cite this article: Bone Joint J 2024;106-B(4):394–400

Aims. Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era. Methods. A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status. Results. A total of 337 patients tested positive for COVID-19. The overall 30-day mortality in these patients was 7.7%: 5.5% in vaccinated patients and 21.7% in unvaccinated patients. There was no significant difference between post-vaccine mortality compared with pre-pandemic 2019 controls (7.7% vs 5.0%; p = 0.068). Independent risk factors for mortality included unvaccinated status, Abbreviated Mental Test Score ≤ 6, male sex, age > 80 years, and time to theatre > 36 hours, in decreasing order of effect size. Conclusion. The vaccination programme has reduced 30-day mortality rates in hip fracture patients with concomitant COVID-19 infection to a level similar to pre-pandemic. Mortality for unvaccinated patients remained high. Cite this article: Bone Joint J 2022;104-B(12):1362–1368

Aims. Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery. Methods. This observational cohort study enrolled consecutively admitted patients with a proximal femoral fracture, for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. A total of 1,803 patients were included, of whom 1,428 had surgery < 24 hours and 375 had surgery ≥ 24 hours after admission. Results. Prolonged total length of stay was found when surgery was performed ≥ 24 hours (median 6 days (interquartile range (IQR) 4 to 9) vs 7 days (IQR 5 to 10); p = 0.001) after admission. No differences in postoperative length of hospital stay nor in 30-day mortality rates were found. In subgroup analysis for time frames of 12 hours each, pressure sores and urinary tract infections were diagnosed more frequently when time to surgery increased. Conclusion. Longer time to surgery due to non-medical reasons was associated with a higher incidence of postoperative pressure sores and urinary tract infections when time to surgery was more than 48 hours after admission. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay. Cite this article: Bone Joint J 2022;104-B(12):1369–1378

Aims. This study aimed to identify risk factors (patient, healthcare system, and socioeconomic) for mortality after hip fractures and estimate their relative importance. Further, we aimed to elucidate mortality and survival patterns following fractures and the duration of excess mortality. Methods. Data on 37,394 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked to data from the Norwegian Patient Registry, Statistics Norway, and characteristics of acute care hospitals. Cox regression analysis was performed to estimate risk factors associated with mortality. The Wald statistic was used to estimate and illustrate relative importance of risk factors, which were categorized in modifiable (healthcare-related) and non-modifiable (patient-related and socioeconomic). We calculated standardized mortality ratios (SMRs) comparing deaths among hip fracture patients to expected deaths in a standardized reference population. Results. Mean age was 80.2 years (SD 11.4) and 67.5% (n = 25,251) were female. Patient factors (male sex, increasing comorbidity (American Society of Anesthesiologists grade and Charlson Comorbidity Index)), socioeconomic factors (low income, low education level, living in a healthcare facility), and healthcare factors (hip fracture volume, availability of orthogeriatric services) were associated with increased mortality. Non-modifiable risk factors were more strongly associated with mortality than modifiable risk factors. The SMR analysis suggested that cumulative excess mortality among hip fracture patients was 16% in the first year and 41% at six years. SMR was 2.48 for the six-year observation period, most pronounced in the first year, and fell from 10.92 in the first month to 3.53 after 12 months and 2.48 after six years. Substantial differences in median survival time were found, particularly for patient-related factors. Conclusion. Socioeconomic, patient-, and healthcare-related factors all contributed to excess mortality, and non-modifiable factors had stronger association than modifiable ones. Hip fractures contributed to substantial excess mortality. Apparently small survival differences translate into substantial disparity in median survival time in this elderly population. Cite this article: Bone Joint J 2022;104-B(7):884–893

Aims. To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome. Methods. This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients’ odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates. Results. A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%). Conclusion. Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates. Cite this article: Bone Joint J 2024;106-B(10):1182–1189

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

Aims. This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods. A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results. The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion. In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781

Aims. The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. Methods. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. Results. Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. Conclusion. PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229–1241

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Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

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Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

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The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

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The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty.

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The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

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Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

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National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

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There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures.

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The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients.

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To investigate if preoperative CT improves detection of unstable trochanteric hip fractures.

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The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

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This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.

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To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients.

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This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA.

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The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

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The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

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Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters.

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We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

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Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

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The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

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The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population.

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There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients.

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Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

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The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

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To evaluate the impact of negative pressure wound therapy (NPWT) on the odds of having deep infections and health-related quality of life (HRQoL) following open fractures.

Aims. We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England. Patients and Methods. An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital. Results and Conclusion. A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of “good recovery”. In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253–61

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The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

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The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients.

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Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

Aims. To determine whether there is any difference in infection rate at 90 days between trauma operations performed in laminar flow and plenum ventilation, and whether infection risk is altered following the installation of laminar flow (LF). Patients and Methods. We assessed the impact of plenum ventilation (PV) and LF on the rate of infection for patients undergoing orthopaedic trauma operations. All NHS hospitals in England with a trauma theatre(s) were contacted to identify the ventilation system which was used between April 2008 and March 2013 in the following categories: always LF, never LF, installed LF during study period (subdivided: before, during and after installation) and unknown. For each operation, age, gender, comorbidity, socio-economic deprivation, number of previous trauma operations and surgical site infection within 90 days (SSI90) were extracted from England’s national hospital administrative Hospital Episode Statistics database. Crude and adjusted odds ratios (OR) were used to compare ventilation groups using hierarchical logistic regression. Subanalysis was performed for hip hemiarthroplasties. Results. A total of 803 065 trauma operations were performed during this time; 19 hospitals installed LF, 124 already had LF, 13 had PV and the type of ventilation was unknown in 28. Patient characteristics were similar between the groups. The rate of SSI90 was similar for always LF and PV (2.7% and 2.4%). For hemiarthroplasties of the hip, the rates of SSI90 were significantly higher for LF compared with PV (3.8% and 2.6%, OR 1.45, p = 0·001). Hospitals installing LF did not see any statistically significant change in the rate of SSI90. Conclusion. The results of this observational study imply that infection rate is similar when orthopaedic trauma surgery is performed in LF and PV, and is unchanged by installing LF in a previously PV theatre. Cite this article: Bone Joint J 2016;98-B:1262–9

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Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland.

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Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

In this retrospective observational cohort study, we describe 17 patients out of 1775 treated for various fractures who developed mycobacterium tuberculosis (MTB) infection after surgery. The cohort comprised 15 men and two women with a mean age of 40 years (24 to 70). A total of ten fractures were open and seven were closed. Of these, seven patients underwent intramedullary nailing of a fracture of the long bone, seven had fractures fixed with plates, two with Kirschner-wires and screws, and one had a hemiarthroplasty of the hip with an Austin Moore prosthesis. All patients were followed-up for two years. In all patients, the infection resolved, and in 14 the fractures united. Nonunion was seen in two patients one of whom underwent two-stage total hip arthroplasty (THA) and the other patient was treated using excision arthoplasty. Another patient was treated using two-stage THA. With only sporadic case reports in the literature, MTB infection is rarely clinically suspected, even in underdeveloped and developing countries, where pulmonary and other forms of TB are endemic. In developed countries there is also an increased incidence among immunocompromised patients. In this paper we discuss the pathogenesis and incidence of MTB infection after surgical management of fractures and suggest protocols for early diagnosis and management. Cite this article: Bone Joint J 2015;97-B:1279–83

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The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

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The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures.

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The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures.

There has been extensive discussion about the effect of delay to surgery on mortality in patients sustaining a fracture of the hip. Despite the low level of evidence provided by many studies, a consensus has been accepted that delay of > 48 hours is detrimental to survival. The aim of this prospective observational study was to determine if early surgery confers a survival benefit at 30 days. Between 1989 and 2013, data were prospectively collected on patients sustaining a fracture of the hip at Peterborough City Hospital. They were divided into groups according to the time interval between admission and surgery. These thresholds ranged from <  6 hours to between 49 and 72 hours. The outcome which was assessed was the 30-day mortality. Adjustment for confounders was performed using multivariate binary logistic regression analysis. In all, 6638 patients aged > 60 years were included. . Worsening American Society of Anaesthesiologists grade (p < 0.001), increased age (p <  0.001) and extracapsular fracture (p < 0.019) increased the risk of 30-day mortality. . Increasing mobility score (p = 0.014), mini mental test score (p < 0.001) and female gender (p = 0.014) improved survival. After adjusting for these confounders, surgery before 12 hours improved survival compared with surgery after 12 hours (p = 0.013). Beyond this the increasing delay to surgery did not significantly affect the 30-day mortality. Cite this article: Bone Joint J 2015;97-B:104–8

Most animal studies indicate that early irrigation and debridement reduce infection after an open fracture. Unfortunately, these studies often do not involve antibiotics. Clinical studies indicate that the timing of initial debridement does not affect the rate of infection but these studies are observational and fraught with confounding variables. The purpose of this study was to control these variables using an animal model incorporating systemic antibiotics and surgical treatment. We used a rat femur model with a defect which was contaminated with Staphylococcus aureus and treated with a three-day course of systemic cefazolin (5 mg/kg 12-hourly) and debridement and irrigation, both of which were initiated independently at two, six and 24 hour time points. After 14 days the bone and hardware were harvested for separate microbiological analysis. No animal that received antibiotics and surgery two hours after injury had detectable bacteria. When antibiotics were started at two hours, a delay in surgical treatment from two to six hours significantly increased the development of infection (p = 0.047). However, delaying surgery to 24 hours increase the rate of infection, but not significantly (p = 0.054). The timing of antibiotics had a more significant effect on the proportion of positive samples than earlier surgery. Delaying antibiotics to six or 24 hours had a profoundly detrimental effect on the infection rate regardless of the timing of surgery. These findings are consistent with the concept that bacteria progress from a vulnerable planktonic form to a treatment-resistant biofilm

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It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management.

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The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.

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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.

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Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and debridement (I&D) and the development of subsequent deep infection has not been established in the literature. Traditionally, I&D of an open fracture has been recommended within six hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multicentre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound I&D (within six hours of injury vs beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open limb fractures requiring surgical treatment.