Introduction. The enhanced recovery after surgery (ERAS) concept in arthroplasty surgery has led to a reduction in postoperative length of stay in recent years. Patients with prolonged length of stay (PLOS) add to the burden of a strained NHS. Our aim was to identify the main reasons. Methods. A PLOS was arbitrarily defined as an inpatient hospital stay of four days or longer from admission date. A total of 2,000 consecutive arthroplasty patients between September 2017 and July 2018 were reviewed. Of these, 1,878 patients were included after exclusion criteria were applied. Notes for 524 PLOS patients were audited to determine predominant reasons for PLOS. Results. The mean total length of stay was 4 days (1 to 42). The top three reasons for PLOS were social services, day-before-surgery admission, and slow to mobilize. Social services accounted for 1,224 excess bed days, almost half (49.2%, 1,224/2,489) of the sum of excess bed days. Conclusion. A preadmission discharge plan, plus day of surgery admission and mobilization on the day of surgery, would have the potential to significantly reduce length of stay without compromising patient care. Cite this article: Bone Joint Open 2020;1-8:488–493

Aims. Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA. Methods. A multicentre, prospective consecutive cohort study was carried out from September 2022 to August 2023. Patients were screened for day-case eligibility using well defined inclusion and exclusion criteria, and discharged when fulfilling predetermined discharge criteria. Day-case eligible patients were scheduled for surgery with intended start of surgery before 1.00 pm. Results. Of 6,142 primary hip and knee arthroplasties, eligibility rates for day-case surgery were 34% for THA (95% CI 32% to 36%), 34% for TKA (95% CI 32% to 36%), and 52% for mUKA (95% CI 49% to 55%). Surgery before 1.00 pm was achieved in 85% of eligible patients. The day-case success rate among patients with surgery before 1.00 pm was 59% (95% CI 55% to 62%) for THA, 61% (95% CI 57% to 65%) for TKA, and 72% (95% CI 68% to 76%) for mUKA. Overall day-case success rates (eligible and non-eligible) were 19% (95% CI 17% to 20%) for THA, 20% (95% CI 18% to 21%) for TKA, and 42% (95% CI 39% to 45%) for mUKA. Adjusted analysis confirmed higher day-case success in eligible mUKA patients (odds ratio 1.9 (1.6 to 2.3)) compared to TKA and THA patients. Primary causes for day-case failure were mobilization issues (9% to 12% between procedures), prolonged spinal anaesthesia (4% to 9%), and postoperative nausea and vomiting (PONV) (4% to 14%). Conclusion. THA and TKA patients showed comparable eligibility (34%) with similar day-case success rates (59 to 61%), whereas mUKA patients demonstrated higher eligibility (52%) and day-case success (72%). Mobilization issues, prolonged spinal anaesthesia, and PONV were the most frequent causes for not being discharged

Aims. 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. Methods. Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated. Results. The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications. Conclusion. Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population. Cite this article: Bone Jt Open 2024;5(4):294–303

Aims. Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy. Methods. Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq). Results. Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation. Conclusion. These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients. Cite this article: Bone Joint Res 2023;12(10):657–666

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. Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

Aims. The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. Methods. A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. Results. Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. Conclusion. COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236–242

Aims. Bone regeneration during treatment of staphylococcal bone infection is challenging due to the ability of Staphylococcus aureus to invade and persist within osteoblasts. Here, we sought to determine whether the metabolic and extracellular organic matrix formation and mineralization ability of S. aureus-infected human osteoblasts can be restored after rifampicin (RMP) therapy. Methods. The human osteoblast-like Saos-2 cells infected with S. aureus EDCC 5055 strain and treated with 8 µg/ml RMP underwent osteogenic stimulation for up to 21 days. Test groups were Saos-2 cells + S. aureus and Saos-2 cells + S. aureus + 8 µg/ml RMP, and control groups were uninfected untreated Saos-2 cells and uninfected Saos-2 cells + 8 µg/ml RMP. Results. The S. aureus-infected osteoblasts showed a significant number of intracellular bacteria colonies and an unusual higher metabolic activity (p < 0.005) compared to uninfected osteoblasts. Treatment with 8 µg/ml RMP significantly eradicated intracellular bacteria and the metabolic activity was comparable to uninfected groups. The RMP-treated infected osteoblasts revealed a significantly reduced amount of mineralized extracellular matrix (ECM) at seven days osteogenesis relative to uninfected untreated osteoblasts (p = 0.007). Prolonged osteogenesis and RMP treatment at 21 days significantly improved the ECM mineralization level. Ultrastructural images of the mineralized RMP-treated infected osteoblasts revealed viable osteoblasts and densely distributed calcium crystal deposits within the extracellular organic matrix. The expression levels of prominent bone formation genes were comparable to the RMP-treated uninfected osteoblasts. Conclusion. Intracellular S. aureus infection impaired osteoblast metabolism and function. However, treatment with low dosage of RMP eradicated the intracellular S. aureus, enabling extracellular organic matrix formation and mineralization of osteoblasts at later stage. Cite this article: Bone Joint Res 2022;11(5):327–341

Aims. Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods. This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination. This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(5):411–418

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Aims. Hand trauma accounts for one in five of emergency department attendances, with a UK incidence of over five million injuries/year and 250,000 operations/year. Surgical site infection (SSI) in hand trauma surgery leads to further interventions, poor outcomes, and prolonged recovery, but has been poorly researched. Antimicrobial sutures have been recognized by both the World Health Organization and the National Institute for Clinical Excellence as potentially effective for reducing SSI. They have never been studied in hand trauma surgery: a completely different patient group and clinical pathway to previous randomized clinical trials (RCTs) of these sutures. Antimicrobial sutures are expensive, and further research in hand trauma is warranted before they become standard of care. The aim of this protocol is to conduct a feasibility study of antimicrobial sutures in patients undergoing hand trauma surgery to establish acceptability, compliance, and retention for a definitive trial. Methods. A two-arm, multicentre feasibility RCT of 116 adult participants with hand and wrist injuries, randomized to either antimicrobial sutures or standard sutures. Study participants and outcome assessors will be blinded to treatment allocation. Outcome measures will be recorded at baseline (preoperatively), 30 days, 90 days, and six months, and will include SSI, patient-reported outcome measures, and return to work. Conclusion. This will inform a definitive trial of antimicrobial sutures in the hand and wrist, and will help to inform future upper limb trauma trials. The results of this research will be shared with the medical community through high impact publication and presentation. Cite this article: Bone Jt Open 2022;3(7):529–535

Aims. Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods. From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results. Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion. Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671–678

Aims. This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results. Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion. There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720

Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Aims. The aim of this study was to evaluate the need for hand trauma services during the COVID-19 pandemic lockdown, specifically related to surgical requirements. This will provide useful information for planning and resource allocation in the event of any further lockdown. Methods. A prospective analsysis of all patients attending our hand trauma unit throughout the UK COVID-19 lockdown period (24 March to 10 May 2020) was carried out. Prospectively collected departmental data from the same period in 2019 was obtained and reviewed for comparison. The number of patients attending clinic, undergoing surgery, the type of surgical procedure, and rate of surgery was compared. Results. In all, 463 patients attended hand trauma services during the lockdown period compared to 793 in 2019 (32% reduction); 190 surgical procedures were carried out during lockdown compared to 236 in 2019 (20% reduction). Intervention rate was higher during the lockdown period (41% compared to 30%). There was no difference in the type of cases. In the first half of lockdown, 47% fewer procedures were performed than in 2019, but in the second half of lockdown 13% more procedures were carried out than the same period in 2019. Conclusion. Requirements for hand trauma surgery remain high during a pandemic lockdown. Attendances and surgical requirements can be expected to steadily return to normal levels during a prolonged lockdown period. Throughout any future lockdown period adequate surgical provision must be maintained for patients with hand injuries. Cite this article: Bone Joint Open 2020;1-10:639–643

Aims. Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland. Methods. A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location. Results. A 21% decrease in radiologically proven trauma was observed on comparison with the same time-period last year. Additionally, a 40% reduction in trauma admissions was observed during the COVID-19 lockdown. A 60% reduction in sports-related injuries and road traffic accident-related injuries was noted during the national lockdown. However, a 17% increase was observed in patients sustaining trauma because of domestic accidents. Conclusion. Variation was observed in both the volume and nature of trauma presentations during the COVID-19 lockdown. As would be expected, a reduction was seen in the number of injuries resulting from outdoor activities. Interestingly, increased rates of domestic injuries were seen during this period which could represent an unintended consequence of the prolonged period of lockdown. Cite this article: Bone Joint Open 2020;1-6:261–266

Aims. Graft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly. Methods. This retrospective study included 2,000 patients (1,156 males and 844 females) who underwent primary ACLR with hamstring autografts between 2007 to 2017. This included 1,063 patients who received pre-soaked saline hamstring grafts for ACLR followed by 937 patients who received pre-soaked gentamicin hamstring grafts for ACLR. All operative procedures were completed by a single surgeon using a standardized surgical technique. Medical notes were reviewed and data relating to the following outcomes recorded: postoperative infection, clinical progress, causative organisms, management received, and outcomes. Results. Superficial wound infection developed in 14 patients (1.31 %) receiving pre-saline soaked hamstring grafts compared to 13 patients (1.38 %) receiving pre-gentamicin soaked hamstring grafts, and this finding was not statistically significant (p = 0.692). All superficial wound infections were treated with oral antibiotics with no further complications. There were no recorded cases of septic arthritis in patients receiving pre-gentamicin soaked grafts compared to nine patients (0.85%) receiving pre-saline soaked grafts, which was statistically significant (p = 0.004). Conclusion. Pre-soaking hamstring autographs in gentamicin does not affect superficial infection rates but does reduce deep intra-articular infection rates compared to pre-soaking hamstring grafts in saline alone. These findings suggest that pre-soaking hamstring autografts in gentamicin provides an effective surgical technique for reducing intra-articular infection rates following ACLR. Cite this article: Bone Jt Open 2021;2(1):66–71

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Objectives. The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular. Methods. English-language publications of human and animal studies categorizing subjects into smokers and nonsmokers were sourced from MEDLINE, The Cochrane Library, and SCOPUS. This review specifically focused on the risk, surgical treatment, and prevention of fracture complications in smokers. Results. Smokers have an increased risk of fracture and experience more complications with delayed bone healing, even if they have already stopped smoking, because some adverse effects persist for a prolonged period. Some risks can be reduced during and after surgery by local and general prevention, and smoking cessation is an important factor in lessening this risk. However, if a patient wants to stop smoking at the time of a fracture, the cessation strategies in reducing tobacco use are not easy to implement. The patient should also be warned that using e-cigarettes or other tobaccos does not appear to reduce adverse effects on health. Conclusion. The evidence reviewed in this study shows that smoking has a negative effect in terms of the risk and treatment of fractures. Cite this article: J. Hernigou, F. Schuind. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res 2019;8:255–265. DOI: 10.1302/2046-3758.86.BJR-2018-0344.R1