Hip fractures commonly occur in older patients, with high levels of frailty and comorbidity. Many of these patients have limited mobility before their fracture, and even after surgery, their mobility may remain limited. It is therefore not surprising that they are at a high risk of developing pressure sores, particularly on their heels, and a variety of devices and interventions have been proposed to reduce this risk. Foam or air mattresses, designed to reduce contact pressure on the patient’s whole body, are now routinely used in many healthcare systems. However, there is wide variation in their design. We developed the WHiTE 14;PRESSURE 3 trial to address the lack of evidence in this area. This is a three-arm multicentre randomized trial including health economic evaluation and recruiting patients from NHS hospitals in the UK. The trial compares standard strategies for the prevention of pressure sores with standard care plus a constant low-pressure device and with standard care plus a heel off-loading device. This annotation describes the development of this trial. Cite this article: Bone Joint J 2025;107-B(2):135–138

The prevalence and onset of pressure sores was studied in 283 patients admitted to a general hospital with either fracture of the proximal femur or for elective hip surgery. Ninety patients developed pressure sores, of which 60 are reported in detail. Most were in women aged 70 or more who had been admitted with hip fractures. The majority of pressure sores started soon after admission, particularly on the day of operation, after which the numbers of new cases decreased. Half the patients had more than one pressure sore and the commonest sites were the sacrum, heels, and buttocks. The mortality in patients with pressure sores was 27% and their mean length of stay in hospital far exceeded that of other patients. The prevention of pressure sores in elderly patients requires more skill and attention than the nurse alone can offer; it demands the help of the whole orthopaedic team

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

Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database. Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X. 2. =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior tendon transfer. Parents admitting to non-compliance were significantly more likely to have a child who required tibialis anterior tendon transfer (X. 2. =5.71, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was 2.0%. Neither medium nor longterm results of Ponseti treatment in the Australian and New Zealand clubfoot have been published. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our center. In our population of Australian clubfoot patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally

Background. Hip fractures cost the NHS £2 billion per annum. British guidelines within 36 hours of admission. However, these guidelines do not consider the time the patient spends between injury and admission. Our study aims to investigate pre-hospital time (PHT) and its effect on outcomes. Primary outcome measures were mortality, length of stay (LOS), pressure sores and abbreviated mental test scores (AMTS). Methods. Hip fracture data was retrospectively collected from our hospital IT system (Clinical Workstation) between February and August 2020. Admission data, ambulance timings, and outcome data was extracted. Statistical analysis was performed using GraphPad Prism V9.5.1. Results. Two hundred eleven data sets were analysed. Mean age was 82.4, with 2:1 Females to males and median ASA of 3. The mean PHT was 690 minutes (85 to 6057). There was a positive correlation between increased PHT and mortality, though this did not reach statistical significance. There was a significant positive association between PHT and LOS (P=0.0027). Increased PHT was associated with lower admission AMTS (P<0.0001) and higher rate of pressure sore formation (P=0.0001). There was also a significantly positive correlation between PHT and time to mobility (P=0.049). Conclusion. There is an unobserved delay in hip fracture patients presenting to the hospital. Current treatment guidelines advocate early surgery but do not consider pre-hospital time. PHT in our patient population is 690 minutes on average, with increasing delay correlating with worse outcomes. Pre-hospital time should be considered when managing hip fracture patients with a view to expedite surgery and medical assessment

Our aim was to determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. All patients admitted to Vancouver General Hospital with this injury between 1998 and 2001 inclusive were identified from our trauma registry. A review of the case notes was performed to determine the delay in time from admission to surgery, age, gender, type of fracture and medical comorbidities. A time-to-event analysis was performed for length of stay. Additionally, a Cox proportional hazards model was used to determine the effect of delay to surgery on the length of stay while controlling for other pertinent confounding factors. Using logistical regression we determined the effect of delay to surgery on in-hospital death, medical complications and the presence of pressure sores, while controlling for confounding factors. Delay to surgery (p = 0.0255), comorbidity (p < 0.0001), age (p < 0.0001) and type of fracture (p = 0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI 1.19 to 4.40). Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimise the risk of complications

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores by analysing prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (4.65 versus 5.76), diabetes mellitus (pressure sore incidence 10.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. While the time interval between fall and admission was not significant, the time interval between admission and surgery was found to be an extremely significant risk factor. A fall in blood pressure during surgery (5.6%) was found to increase risk. Patients who underwent a dynamic hip screw were more likely to develop pressure sores (incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery or type of anaesthesia. Our incidence of pressure sores is lower than previously reported (30%). Whilst determining factors that increase the risk of pressure sores may not be sufficiently reliable to be used for the individual patient, taking appropriate preventative measures can reduce the incidence, particularly with reference to (optimising the patient pre-operatively and) reducing delays to surgery

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores. We have analysed prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (5.7 versus 6.7), diabetes mellitus (pressure sore incidence 9.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. Among surgical factors related to an increased risk was a fall in blood pressure during surgery (5.6%). Patients who underwent a dynamic hip screw were more likely to develop pressure sores (pressure sore incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery of type of anaesthesia. Our study indicates that the current incidence of pressure sores is lower that that previously reported (30%). Whilst it is possible in a large population of patients to determine factors that increase the risk of pressure sores, these are not sufficiently reliable to be used for an individual patient

To compare the actual with the reported incidence of pressure sores to determine the accuracy of data (classification errors) and completeness of data (differences between manual and computer generated figures), retrospective data was collected regarding pressure sore rates following primary elective total hip arthroplasty operations carried out in 2001. Pressure sores rates were noted by nursing staff and entered into a computer database. Four consultant orthopaedic surgeons were involved, across 2 sites – 1 NHS (PRH) and 1 local private hospital. Preliminary audit reports indicated an alarmingly high pressure sore rate across the two units – 17/172 (9.9%) PRH and 23/71 (32.4%) private hospital. Two major errors were revealed. In terms of accuracy of data, grade 1 areas (erythema without active ulceration) were included at both sites. These are only potential sites of pressure sores and should not have been used to calculate actual pressure sore rate. In terms of completeness of data, manual verification of the number of operations performed revealed a discrepancy between the theatres’ logbook entries and private unit computer figures. 97 rather than 71 operations were performed. There was no such discrepancy at the NHS site. The data was reanalysed to obtain the actual pressure sore rate. For the NHS unit, grade 1areas were subtracted, causing the rate to fall from 32.4% to 1.0%. The two errors caused a dramatic and significant difference between reported and actual pressure sore rate. Poor data collection leads to inaccurate audit, leading to inappropriate management. The concern is that similar errors, accumulated across key complication targets and specialities, will have a profound impact on NHS star ratings

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. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

Introduction and Purpose. Metacarpal fractures constitute approximately one third of all hand fractures. The majority of these fractures are treated by conservative non-surgical methods. The aim of this study is to obtain the appropriate anatomical alignment of the fracture with dynamic metacarpal stabilization splint (DMSS) and to maintain the proper bone anatomy until the union is achieved. In addition, by comparing this method with short arm plaster splint (SAPS) application, it is aimed to evaluate whether patients are superior in terms of comfort, range of motion (ROM) and grip strength. Materials and Methods. In our study, SAPS or DMSS was applied to the patients with 5th metacarpal neck fracture randomly after fracture reduction and followed for 3 months. A total of 119 patients with appropriate criteria were included in the study. Radiological alignment of the fracture and amount of joint movements were evaluated during follow-up. Grip strength was evaluated with Jamar dynamometer. EQ-5D-5L and VAS scores were used for clinical evaluation. Results. 103 patients completed their follow-up. 51 patients were treated with SAPS and 52 patients were treated with DMSS. The mean age of the SAPS was 29.5 (SD ± 9.4; 16–53 years) and the mean age of the DMSS group was 27.8 (SD ± 11.6; 16–63). Pressure sores was seen in 5 patients in the DMSS group, while no pressure sore was seen in the SAPS (p = 0.008). There was no significant difference between the two groups in the VAS scores at all times. There was no significant difference between the mean dorsal cortical angulation (DCA) before the reduction, after the reduction and at the third month follow-ups. There was no statistically significant difference between the length of metacarps at first admittion before reduction, after reduction and at third month follow-ups. When the grip strength of the two groups were compared as a percentage, the grip strength of the patients in the DMSS group was found to be higher at 1st month, 2nd month and 3rd month (p <0.001). When the ROM values of the patients were evaluated, DMSS group had a higher degree of ROM in the first month compared to the SAPS group (p <0.001). No statistically significant difference was detected among groups at third month in the ROM of the IP and MP joints. However, wrist ROM was statistically higher in DMSS group at 3rd month (p <0.05). There was a statistically significant difference between EuroQol scores in favor of DMSA group (p <0.05). Discussion and Conclusion. In stable 5th metacarpal neck fractures, DMSA is as effective as SAPS to maintain bone anatomy. In addition, DMSA can be preferred for fixation plaster splint or circular plaster applications for the prevention of reduction in boxer fractures, with the advantage of having high clinical scores, which is an indication of early acquisition of grip strength, ease of use and patient comfort

Debate continues about the best treatment for patients over 65 years with non-displaced subcapital hip fractures: internal fixation (IF) or hemiarthroplasty (HA). Surgical aggression, mortality, complications and recovery of walking ability after 1year have been compared between both treatments. Match-paired comparison of 2 retrospective cohorts. 220 patients with IF vs 220 receiving a cemented bipolar HA. Matching by age (82.6±7.16 years (65–99)), sex (74.5% women), year of intervention (2013–2021) and ASA scale (24.2% ASA II, 55.8% III, 20.0% IV). Age (p=0.172), sex (p=0.912), year of intervention (p=0.638) and ASA scale (p=0.726) showed no differences. Surgical aggression smaller in IF: Surgical time (p< 0,00001), haemoglobin/haematocrit loss (p <0,00001), need for transfusion (p<0,00008), in-hospital stay (p<0,00001). Mortality: higher in-hospital for hemiarthroplasties (12 deaths (5.5%) vs 1 (0.5%) (p=0.004) (RR=12, 1.5–91.5)). But no significant differences in 1-month (13 hemiarthroplasties, 6%, vs 9 osteosynthesis, 4.1%) and 1-year mortality (33 hemiarthroplasties, 15%, vs 35, 16%). Medical complications: no differences in urinary/respiratory infections, heart failure, ictus, myocardial infarction, digestive bleeding, pressure sores or pulmonary embolus (p=0.055). Surgical complications: no significant differences. HA: 6 intraoperative (2,7%) and 5 postoperative periprosthetic fractures (2,3%), 5 infections (2,3%), 10 dislocations (4,5%), 3 neurovascular injuries. IF: 10 acute fixation failures (4,5%), 2 infections (0,9%), 9 non-unions (4,1%), 16 ischemic necrosis (7,3%). Functional results: no significant differences; 12 patients in each group (5,5%) never walked again (p=1), 110 HA (50%) and 100 IF (45.5%) suffered worsening of previous walking ability (p=0.575), 98 HA (44%) and 108 IF patients (49%) returned to pre-fracture walking ability (p=0.339). Fixation with cannulated screws may be a better option for non-displaced femoral neck fractures because recovery of walking ability and complications are similar, while surgical aggression and in-hospital mortality are lower

Fracture related infections (FRI) are debilitating complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. This study aims to determine risk factors associated with FRI treatment failure, allowing clinicians to optimise them prior to treatment and identify patients at higher risk. A major trauma centre database was retrospectively reviewed over a six-year period. Of the 102 patients identified with a FRI (66 male, 36 female), 29.4% (n=30) had acute infections (onset <6 weeks post-injury), 34.3% (n=35) had an open fracture. Open fractures were classified using Gustilo-Anderson (GA) classification (type 2:n=6, type 3A:n=16, type 3B:n=10, type 3C:n=3). Patients with periprosthetic infections of the hip and knee joint, those without prior fracture fixation, soft tissue infections, diabetic foot ulcers, pressure sore infections, patients who died within one month of injury, <12 months follow-up were excluded. FRI treatment failure was defined as either infection recurrence, non-union, or amputation. Lifestyle, clinical, and intra-operative data were documented via retrospective review of medical records. Factors with a P-value of p<0.05 in univariate analysis were included in a stepwise multivariate logistic regression model. FRI treatment failure was encountered in 35.3% (n=36). The most common FRI site was the femoral shaft (16.7%; n=17), and 15.7% (n=16) presented with signs of systemic sepsis. 20.6% (n=21) had recurrent infection, 9.8% (n=10) had non-union, and 4.9% (n=5) required an amputation. The mean age at injury was 49.71 years old. Regarding cardiovascular risk factors, 37 patients were current smokers (36.3%), 31 patients were diabetics (30.4%), and 32 patients (31.4%) were obese (BMI≥30.0). Average follow-up time was 2.37 (range: 1.04-5.14) years. Risk factors for FRI treatment failure were BMI>30, GA type 3c, and implant retention. Given that FRI treatment in 35.3% (36/102) ended up in failure, clinicians need to take into account the predictive variables analysed in this study, and implement a multidisciplinary team approach to optimise these factors. This study could aid clinicians to redirect efforts to improve high risk patient management, and prompt future studies to trial adjuvant technologies for patients at higher risk of failure

A prospective study of 142 consecutive patients admitted with fracture of the neck of femur was performed. 42 patients were operated within 24 hours of time of fracture (group 1), 46 within 24 to 48 hours (group 2) and 47 more than 48 hours later (group 3). Three patients were treated conservatively and in four patients the exact time of fracture was not known. The reason for delay of the operation was lack of theatre space in the majority of cases (64 patients). Medical problems accounted for delay in only 10 patients.Seven patients out of 42 in group 1 died within four month (16.7%), compared to 11 of 46 in group 2 (23.9%), and 6 out of 47 in group 3 (12.8%). This difference was not statistically significant. There was no significant difference in requirement for pre- and postoperative blood transfusion between the three groups. No patient operated within 24 hours developed pressure sores. Three patients in group 2, and six patients in group 3 developed pressure sores. Chest infections occurred in three patients in group 2, and in three patients in group 3. None of the patients operated on within 24 hours developed a chest infection, wound infection or urinary tract infection. Two patients who had a Girdlestone procedure for deep infection were operated more than 48 hours after the fracture. One patient requiring drainage for wound infection had the operation 47 hours after the fracture.There were no superficial or deep wound infections, pressure sores, or chest infections if operated on within 24 hours of fracture. There was no difference in the requirement for blood transfusion. Patients operated within 24 to 48 hours of fracture had the highest mortality, although this was not statistically significant

Aims. In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip. . Patients and Methods. All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days. . Results. There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals. Conclusion. These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. Take home message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip. . Cite this article: Bone Joint J 2016;98-B:414–19

The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic clubfoot deformity. All patients were enrolled in the Pediatric Clubfoot Research Registry between 2003 and April 2021. Inclusion criteria consisted of patients presenting at after percutaneous Achilles tenotomy. Postal codes were used to determine distance from patients’ home address to the hospital. Patients were divided into three groups based on distance traveled to hospital: those living within the city, within the Greater Metro Area (GMA) and outside of the GMA (non-GMA). The primary outcome evaluated was occurrence of deformity relapse and secondary outcomes included need for surgery, treatment interruptions/missed appointments, and complications with bracing or casting. A total of 320 patients met inclusion criteria. Of these, 32.8% lived in the city, 41% in the GMA and 26% outside of the GMA. The average travel distance to the treatment centre in each group was 13.3km, 49.5km and 264km, respectively. Over 22% of patients travelled over 100km, with the furthest patient travelling 831km. The average age of presentation was 0.91 months for patients living in the city, 1.15 months for those within the GMA and 1.33 months for patients outside of the GMA. The mean number of total casts applied was similar with 7.1, 7.8 and 7.3 casts in the city, GMA and non-GMA groups, respectively. At least one two or more-week gap was identified between serial casting appointments in 49% of patients outside the GMA, compared to 27% (GMA) and 24% (city). Relapse occurred in at least one foot in 40% of non-GMA patients, versus 27% (GMA) and 24% (city), with a mean age at first relapse of 50.3 months in non-GMA patients, 42.4 months in GMA and 35.7 months in city-dwelling patients. 12% of the non-GMA group, 6.8% of the GMA group and 5.7% of the city group underwent surgery, with a mean age at time of initial surgery of 79 months, 67 months and 76 months, respectively. Complications, such as pressure sores, casts slips and soiled casts, occurred in 35% (non-GMA), 32% (GMA) and 24% (city) of patients. These findings suggest that greater travel distance for clubfoot management is associated with more missed appointments, increased risk of relapse and treatment complications. Distance to a treatment center is a modifiable barrier. Improving access to clubfoot care by establishing clinics in more remote communities may improve clinical outcomes and significantly decrease the burdens of travel on patients and families

Aim. This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture. Method. This study identified a consecutive series of 2,822 (2,052 female, 73%) patients who underwent either hemiarthroplasty (n=1,825, 65%) or fixation (DHS) (n=997, 35%) for fractured neck of femur performed between January 2009 and June 2015 at our institution. Full patient demographics, co-morbidity and peri-operative complication data were determined. The majority of patients were either ASA 2 (n=663, 23%) or ASA 3 (n=1,521, 54%), mean age = 81.3 years (SD 10.3). All patients were followed up post-operatively by a dedicated surgical site infection (SSI) monitoring team in order to identify patients who developed a PJI within 1 year. A stepwise multivariable logistic regression model was used to identify patient and surgical factors associated with increased risk of infection. Predictors with a p-value of <0.20 in the univariate analysis were included in the multivariate analysis. Results. Thirty-nine (39) cases of deep periprosthetic infection were identified (hemiarthroplasty n=35, DHS n=4) representing an overall deep infection rate of 1.4% (hemiarthroplasty 1.9%, DHS 0.4%). The most common infecting pathogen was a pure growth of coagulase negative Staphylococcus (n=9, 23%) followed by a pure growth of Staphylococcus aureus (n=7, 18%). An increased risk of PJI was observed in patients who underwent hemiarthroplasty compared to those treated by fixation (odds ratio (OR) 6.50, 95%CI 2.26 – 18.7, p=0.001). Of patient factors, only blood transfusion within 30 days (OR 3.51, 95%CI 1.72 – 7.13, p=0.001) and the presence or development of pressure sores on or during admission (OR 2.99, 95%CI 1.24 – 7.19, p=0.015) were significantly associated with an increased risk of development of PJI. Use of high-dose dual antibiotic cement (gentamicin and clindamycin) was associated with a two-fold reduction in the risk of PJI (OR 0.39, 95%CI 0.20 – 0.76, p=0.005) vs standard dose gentamicin antibiotic cement. Conclusions. This study found: 1) a deep infection rate similar to that reported earlier from large number studies from the UK, 2) a six-fold higher deep infection rate in hemiarthroplasties, compared to internal fixations, and 3) a three-fold higher infection rate in patients who suffer concomitant pressure sores or receive a blood transfusion up to 30 days post-operatively

Aims: Pressure sores are potentially serious complications caused by capillary closure due to extended periods of immobilization such as during surgery. Jellypads are available to reduce this risk but are costly and have been shown to harbour bacteria, thereby posing as an infective risk in implant surgery. The aim of this study is to investigate the potential use of more cost effective, clean, disposable product, without compromising on efficacy. Methods: Currently marketed (jellypad) and novel (bubblewrap) pressure relief products were used in this study to compare pressures generated when a subject sat on the different products. Varying diameter bubblewrap in differing layer structure was used to assess whether (a) the novel material offered better pressure relief and if so, (b) which configuration provided the best pressure dispersion. Results: Our results show that bubblewrap seems to offer better relief of pressure than jellypad. Two to four layers of 10 mm diameter bubblewrap used in opposite directions was the optimum configuration. Conclusion: Based on our investigations, we believe that bubblewrap is a better product for the prevention of pressure sores. Bubble-wrap results in lower peak and average pressure values than jellypad. Moreover, bubblewrap is cheap, disposable and is less likely to transmit infections

Purpose: Numerous implants used in repairing a trochanteric fracture of the hip are currently available. The purpose of this prospective study was to determine the complications and results of the percutaneous compression plate (PCCP), a relatively new device versus the conventional dynamic hip screw (DHS). Materials and Methods: Between 2001–2003, 110 consecutive patients with trochanteric fractures were treated in our department. Fifty-five fractures were stabilized using the PCCP and 55 fractures were treated with the DHS. Results were analyzed according to fracture pattern, type of implant, quality of fracture reduction and position of implant. Function was assessed on the basis of pain, walking aids and walking capability. Results: Forty-seven (85%) of 55 hips treated with PCCP healed without additional treatment and complications. Forty-three (78%) treated with DHS healed without additional treatment and complications. Complications among 8 patients (15%) of the PCCP group were: deep vein thrombosis, cardiac complication, chest infection and pressure sores. Complications among 12 patients (22%) of the DHS group were: implant failure (7%), deep wound infection, deep vein thrombosis and pressure sores. Conclusions: Use of the PCCP implant provides similar and occasionally better results compared to those obtained with the conventional DHS device. The most outstanding advantage of the PCCP device was no implant failure or implant cut out