The impact of COVID-19 on mortality after hip fracture : a population cohort study from England.

AIMS: Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. METHODS: We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. RESULTS: Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. CONCLUSION: COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival.Cite this article: Bone Joint J 2022;104-B(10):1156-1167.

Reoperation and revision rates at ten years after 1,312 cemented Thompson's hemiarthroplasties : any need to change to a different implant?

AIMS: Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson's hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. METHODS: Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries. RESULTS: In total, 1,312 Thompson's hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%. CONCLUSION: The Thompson's stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson's implant as a cost-effective option for frail hip fracture patients.Cite this article: Bone Jt Open 2022;3(9):710-715.

Can radiographs of hip fractures predict subsequent hip fractures? A shape modelling analysis.

INTRODUCTION: The geometrical shape of the proximal femur has previously been shown to predict primary hip fractures. Hip fractures are routinely diagnosed on plain radiographs of the pelvis, and these have both hips viewable. We have investigated if statistical shape modelling of the uninvolved hip on plain radiographs, at the time of the first hip fracture episode, could predict a subsequent 'second fracture' on that (uninvolved) side. MATERIALS AND METHODS: 60 radiographs taken at the time of the index hip fracture were blinded and separated into two arms; patients sustaining one hip fracture only (n=30), and those who went on to sustain a second fracture (n=30), over the three-year follow-up period. Two separate shape models were used for these groups and compared using t-tests or Mann-Whitney U-tests, along with Cohen's d to measure the effect size of each measure. RESULTS: We found no statistically significant difference in the shape of the femur between the first fracture and second fracture group (p>0.05) and no results reached a "medium" effect size (Cohen's d <0.5). CONCLUSIONS: Shape modelling is feasible and can be applied in the routine clinical setting. However, we were unable to elucidate any predictive value in this relatively small sample. A reliable radiograph-based method of identifying patients at risk of second fracture would be of value in planning prevention, service provision, and cost analysis. Further work is required and a study with more patients might exclude the type 2 error in our work.

GP contact with patients after treatment for hip fracture: frequency and determinants.

BACKGROUND: Patients with hip fracture have complex medical issues, both at the time of admission and after discharge from hospital. We have observed a surge in patient-initiated and carer-initiated contacts with general physicians (GPs) for periods longer than those usually reported, in a series of patients sustaining fractures from July 2008 to September 2013. OBJECTIVES: To establish (1) the frequency of contact with GPs (primary outcome) and (2) the factors influencing the frequency of different modes of contact. METHODS: Ten GP practices in West Northumberland were asked to retrospectively identify patients sustaining hip fractures, and to provide data on the number of GP contacts (patient visits to GP, telephone consultations, GP visits to patient's home) up to 1 year before and 1 year after fracture. Generalised linear models (GLM) were constructed using number of postfracture GP contacts as response variable; age, gender, residential status, number of prefracture contacts and days to contact postfracture were covariates. RESULTS: Each patient recorded cumulative 8.4 GP contacts before and 10.79 contacts after fracture. There were significantly more telephone contacts with GPs and GP home visits, but significantly fewer patient visits to GP clinics. In the GLM analysis, patient age and number of prefracture GP contacts predicted all types of postfracture contacts, while gender was not. Patients discharged home visited their GPs five times more frequently than those discharged to institutional care. CONCLUSIONS: After hip fractures, telephone contacts and GP visits to patients' homes increase, but patient visits to GP clinics decrease, influenced by age and residential status.

Occurrence, management and outcomes of hip fractures in patients with Parkinson's disease.

INTRODUCTION: Hip fractures can be debilitating, especially in patients with pre-existing Parkinson's disease; they have reportedly worse outcomes than non-Parkinson's disease patients. SOURCES OF DATA: A computerized literature search on PubMed, Medline, Embase, and CINAHL, supplemented by a manual search of related publications. AREAS OF AGREEMENT: Parkinson's disease patients were found to have significantly lower bone mineral density; higher incidence of falls and hip fractures; delays to receiving their Parkinson's disease medication and surgery; higher risk of pneumonia, urinary infection, pressure sores, post-operative mortality; surgical complications and sequelae, including failed fixation, dislocation, longer hospital stay, re-operation; and increased risk of contralateral hip fracture. AREAS OF CONTROVERSY: Regain of mobility and return to previous residential status have been variably reported. GROWING POINTS: All Parkinson's disease patients should be screened and considered for primary prevention treatment. On admission with hip fractures, attention should be paid to avoid delays to medication, ensuring safe anaesthetic and timely surgery, and post-operative chest physiotherapy and mobilization. RESEARCH: Research is needed in minimizing the bone-resorptive effects of anti-Parkinson's disease medication.

The risk of cardiorespiratory deaths persists beyond 30 days after proximal femoral fracture surgery.

INTRODUCTION: 30-day mortality is routinely used to assess proximal femoral fracture care, though patients might remain at risk for poor outcome for longer. This work has examined the survivorship out to one year of a consecutive series of patients admitted for proximal femoral fracture to a single institution. We wished to quantify the temporal impact of fracture upon mortality, and also the influence of patient age, gender, surgical delay and length of stay on mortality from both cardiorespiratory and non-cardiorespiratory causes. PATIENTS AND METHODS: Data were analysed for 561 consecutive patients with 565 fragility type proximal femoral fractures treated surgically at our trauma unit. Dates and causes of death were obtained from death certificates and also linked to data from the Office of National Statistics. Mortality rates and causes were collated for two time periods: day 0-30, and day 31-365. RESULTS: Cumulative incidence analysis showed that mortality due to cardiorespiratory causes (pneumonia, myocardial infarction, cardiac failure) rose steeply to around 100 days after surgery and then flattened reaching approximately 12% by 1 year. Mortality from non-cardiorespiratory causes (kidney failure, stroke, sepsis etc.) was more progressive, but with a rate half of that of cardiorespiratory causes. Progressive modelling of mortality risks revealed that cardiorespiratory deaths were associated with advancing age and male gender (p<0.001 for both), but the effect of age declined after 100 days. Non-cardiorespiratory deaths were not time-dependent. CONCLUSION: We believe this analysis extends our understanding of the temporal impact of proximal femoral fracture and its surgical management upon outcome beyond the previously accepted standard (30 days) and supports the use of a new, more relevant timescale for this high risk group of patients. It also highlights the need for planning and continuing physiotherapy, respiratory exercises and other chest-protective measures from 31 to 100 days.

Achieving best practice tariff may not reflect improved survival after hip fracture treatment.

OBJECTIVE: The best practice tariff (BPT) incentivizes hospitals in the England and Wales National Health Service to provide multiprofessional care to patients with hip fractures. The initial six targets included: 1) admission under consultant-led joint orthopedic-geriatric care, 2) multidisciplinary assessment protocol on admission, 3) surgery within 36 hours, 4) geriatrician review within 72 hours, 5) multiprofessional rehabilitation, and 6) assessment for falls and bone protection. We aimed to examine the relationship between BPT achievement and important patient outcomes and whether the BPT could predict these independently of other validated predictors. MATERIALS AND METHODS: A retrospective review was conducted on 516 patient episodes. Four outcomes were defined: 1) 30-day mortality, 2) 365-day mortality, 3) postoperative length of stay on trauma ward (LOS-T), and 4) total post-operative hospital LOS (LOS-H). Patient episodes were grouped as follows: 1) group 1, pre-BPT, 2) group 2, BPT achievers, 3) group 3, BPT fails. These were compared for mortality (χ (2) test) and for LOS (Kruskal-Wallis test). Event analysis was done for groups 2 and 3 using generalized linear modeling, with age, sex, American Society of Anesthesiologists grade, hemoglobin, albumin, creatinine, and BPT achievement evaluated as predictors. RESULTS: The three groups did not differ significantly in baseline characteristics or outcomes. In the event analysis, the risk of 30-day mortality was related only to abnormal creatinine (P=0.025); mortality at 365 days was related significantly to low albumin (P=0.023) and weakly to abnormal creatinine (P=0.089). The risks of both increased LOS-T and LOS-H were related to age only (P=0.052, P<0.001, respectively). CONCLUSION: Achieving BPT does not predict any outcome of interest on its own.

Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures.

BACKGROUND AND PURPOSE: Enhanced Recovery (ER) is a well-established multidisciplinary strategy in lower limb arthroplasty and was introduced in our department in May 2008. This retrospective study reviews short-term outcomes in a consecutive unselected series of 3,000 procedures (the "ER" group), and compares them to a numerically comparable cohort that had been operated on previously using a traditional protocol (the "Trad" group). METHODS: Prospectively collected data on surgical endpoints (length of stay (LOS), return to theater (RTT), re-admission, and 30- and 90-day mortality) and medical complications (stroke, gastrointestinal bleeding, myocardial infarction, and pneumonia within 30 days; deep vein thrombosis and pulmonary embolism within 60 days) were compared. Results ER included 1,256 THR patients and 1,744 TKR patients (1,369 THRs and 1,631 TKRs in Trad). The median LOS in the ER group was reduced (3 days vs. 6 days; p = 0.01). Blood transfusion rate was also reduced (7.6% vs. 23%; p < 0.001), as was RTT rate (p = 0.05). The 30-day incidence of myocardial infarction declined (0.4% vs. 0.9%; p = 0.03) while that of stroke, gastrointestinal bleeding, pneumonia, deep vein thrombosis, and pulmonary embolism was not statistically significantly different. Mortality at 30 days and at 90 days was 0.1% and 0.5%, respectively, as compared to 0.5% and 0.8% using the traditional protocol (p = 0.03 and p = 0.1, respectively). INTERPRETATION: This is the largest study of ER arthroplasty, and provides safety data on a consecutive unselected series. The program has achieved a statistically significant reduction in LOS and in cardiac ischemic events for our patients, with a near-significant decrease in return to theater and in mortality rates.

Clinical outcome and cost comparison of carpal tunnel wound closure with monocryl and ethilon: a prospective study.

This prospective non-randomised two-cohort study compares the use of an absorbable suture (Poliglecrapone [Monocryl]: Group A) and a non-absorbable suture (Polyamide [Ethilon]: Group B) in wound closure after elective carpal tunnel decompression. The primary outcome was scar cosmesis as assessed by the Stonybrook Scar Evaluation Scale (SBSES); the financial cost of wound closure was compared as a secondary outocome. All fifty patients completed follow-up. At six weeks, there was no significant difference in the two groups regarding scar tenderness (p = 0.5), although residual swelling was more evident in the absorbable group (p = 0.2). The mean SBSES score at six weeks was 4.72 in Group A, and 4.8 in Group B (p = 0.3). The unit cost per closed wound of Monocryl was three times than Ethilon (p < 0.05). Ethilon is thus cost-effective without compromising the cosmetic outcome, and we recommend using this as the preferred suture for closure of carpal tunnel wounds.

Outcomes of four-corner arthrodesis using the Hubcap circular plate.

We present results of four-corner carpal arthrodesis with the Acumed Hubcap circular plate performed at our unit. Eight patients underwent eight procedures over five years, for scapholunate advanced collapse (five wrists) and scaphoid non-union advanced collapse (three wrists). Outcomes included range of motion, quickDASH scores, and visual analogue scores for satisfaction. At final follow-up, mean flexion-extension arc was 56°, mean radial-ulnar deviation 29° and mean quickDASH score was 23/100. Mean score for satisfaction was 7.7/10 (77%). Seven out of eight (87.5%) patients said they would have it done again, and would also recommend it to others. Radiological union was achieved in all cases. One screw broke in one arthrodesis without causing symptoms. The functional outcomes with our use of the Hubcap are comparable to those reported in literature to date with other circular plates (e.g. Spider plate). There were no non-unions, which is the main reported complication with these plates.

Low oxygen tension is critical for the culture of human mesenchymal stem cells with strong osteogenic potential from haemarthrosis fluid.

Satisfactory osseous tissue integration of the soft tissue graft with bone is the mainstay of healing following surgical reconstruction of the anterior cruciate ligament (ACL). However, tissue remodelling is slow and significantly impacts on quality of life by delaying return to work and sport and accelerating the onset of degenerative diseases such as osteoarthritis. Delivery of multipotent human mesenchymal stem cells (hMSCs) at surgery could enhance osseous tissue integration. We aim to use hMSCs derived from haemarthrosis fluid (HF) (the intra-articular bleed accrued post-trauma) which is aspirated and discarded as clinical waste. With the aim of improving our bioprocessing methodologies for clinical translation we have investigated the effect of low oxygen tension on the derivation and osteogenic potential of this novel HF-hMSC population. Mononuclear cells were isolated from HF aspirated samples and divided for derivation and culture under normal or low oxygen tension. HF-hMSCs were derived from 100 % of cultures under low oxygen tension compared to 71 % for normal oxygen tension; this was coupled with increased CFU-Fs. We investigated the osteogenic potential and cellular health of HF-hMSC populations following ex vivo expansion. HF-hMSC populations showed enhanced matrix mineralisation and cellular health when differentiated under low oxygen tension. This positive effect of low oxygen on osteogenesis and cellular health was reduced with prolonged culture. These data demonstrate that derivation and culture of HF-hMSC populations under low oxygen tension will enable the translation of a cellular therapy for the treatment of broad patient numbers with optimal osteogenic potency and cellular vitality.

Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program. A study of 4,500 consecutive procedures.

BACKGROUND AND PURPOSE: Our unit started to use routine multimodal techniques to enhance recovery for hip and knee arthroplasty in 2008. We have previously reported earlier discharge, a trend toward a reduction in complications, and a statistically significant reduction in mortality up to 90 days after surgery. In this study, we evaluated the same cohort to determine whether survival benefits were maintained at 2 years. PATIENTS AND METHODS: We prospectively evaluated 4,500 unselected consecutive total hip and knee replacements. The first 3,000 underwent a traditional protocol (TRAD) and the later 1,500 underwent an enhanced recovery protocol (ER). Mortality data were collected from the Office of National Statistics (UK). RESULTS: There was a difference in death rate at 2 years (TRAD vs. ER: 3.8% vs. 2.7%; p = 0.05). Survival probability up to 3.7 years post surgery was significantly better in patients who underwent an ER protocol. INTERPRETATION: This large prospective case series of unselected consecutive patients showed a reduction in mortality rate at 2 years following elective lower-limb hip and knee arthroplasty following the introduction of a multimodal enhanced recovery protocol. This survival benefit supports the routine use of an enhanced recovery program for hip and knee arthroplasty.

Does the timing of presentation of neck of femur fractures affect the outcome of surgical intervention.

OBJECTIVES: There is growing emphasis on minimizing surgical delay for neck of femur fractures. Surgery within 36 h of diagnosis by the emergency department (ED) is classed as a key performance indicator. We aimed to determine the influence of the effect of time of presentation to the ED on surgical delay and 90-day mortality. The influence of age (<85 vs. ≥85 years) on these outcomes was also examined. METHODS: A retrospective study was carried out. Data on 663 patients admitted over 30 months to a single unit were analysed for times of presentation to ED, radiographs in ED, admission to trauma ward and surgery. The delays to admission and surgery were calculated. The patients were divided into four 'time classes' depending on their time of presentation in the ED (i.e. 00:00-06:00, 06:00-12:00, 12:00-18:00 and 18:00-00:00) and into two 'age cohorts' (i.e. <85 and ≥85 years). RESULTS: The four 'time classes' included 58, 157, 259 and 189 patients, respectively. Patients who presented between 00:00 and 06:00 had a significantly reduced surgical interval and delay (P<0.001). There were no significant differences in the outcome measures, that is 36-h operation and 90-day mortality rates between the four classes. Overall, 386 patients were aged below 85 years and 277 were aged at least 85 years. Admission and surgical delays were similar between the two age cohorts, as were the 36-h operation rates. The 90-day mortality rates were 5.7 and 17.7%, respectively (P<0.0001). CONCLUSION: This study showed that the time of presentation to the ED could influence surgical delay. However, there was no direct relationship between surgical delay and 90-day mortality.

Elderly men with renal dysfunction are most at risk for poor outcome after neck of femur fractures.

BACKGROUND: both acute and chronic renal dysfunction (ARD and CRD) have been reported to influence outcomes after neck of femur fractures. We have examined the relationship between the length of stay, mortality and renal dysfunction using biomarkers. These included pre-operative (admission) serum concentrations of urea, creatinine and albumin, and estimated glomerular filtration rates (eGFR) derived from four- and six-variable Modification of Diet in Renal Disease (MDRD) study equations. METHODS: complete outcomes data for 566 patients and the patterns of variations in the biomarkers were analysed using generalised linear models. Cox-proportional hazard analyses investigated the association between kidney function (as assessed by the above-mentioned biochemical data) and post-operative length of stay and mortality. All patients were stratified for CRD according to their eGFR. RESULTS: serum urea and creatinine were significantly, positively correlated with age. After adjusting for age and sex, risk of mortality was positively related to six-variable eGFR and creatinine, and marginally so for urea. One-year mortality risk thus worsened with stages of CRD (1-4), increasing age and male gender. Risk of discharge from trauma ward, the length of stay in trauma ward and the overall length of stay were not related to urea and creatinine, but were negatively related to both four- and six-variable eGFR. CONCLUSIONS: the study has identified elderly renal-impaired males as the subgroup of patients most at risk for poor survival. This subgroup may require a more targeted approach to the management of their fluid and electrolyte homoeostasis to help improve their outcomes.

Factors influencing length of stay and mortality after first and second hip fractures: an event modeling analysis.

OBJECTIVE: The aim of this study was to investigate factors influencing length of stay and mortality in first and second hip fractures. DESIGN: This was a retrospective study with data analysis. SETTING: The study was conducted at a level 1 trauma center. PATIENTS: Six hundred and seventy-two patients treated for hip fractures (OTA 31-A, 31-B, 32-A1.1) over 30 months were split into 2 groups. 1FG: Six hundred and ten patients (90.8%) suffered a fracture for the first time. 2FG: Sixty-two patients (9.2%) had previously sustained contralateral fractures. INTERVENTION: Dynamic hip screws or cephalomedullary nails (31-A fractures); cephalomedullary nails (32-A1.1); dynamic hip screws or cannulated screws (undisplaced 31-B fractures); and hemiarthroplasty (displaced 31-B fractures) were used. MAIN OUTCOME MEASURES: Postoperative lengths of stay on trauma ward (LOS-T) on the rehabilitation unit (LOS-R) and in hospital (LOS-H) were calculated. Dates of death were recorded. Event analysis and structural equation modeling were used to assess the impact of second fractures, fracture types, age, gender, and ASA grades on these. RESULTS: : The 2 groups were comparable in gender distribution, ASA grades, fracture types, LOS, and mortality at 120 days. 2FG patients were older than 1FG (mean 83.3 vs 80.2 years) with a higher proportion being discharged to institutional care (35.5% vs 18.5%). Event modeling analysis showed that LOS-T was dependent on ASA grade, whereas mortality was dependent on ASA grade, age, and gender. Second fractures were not related to the risks of increased LOS-T, LOS-R, and mortality. CONCLUSIONS: Second fractures per se do not increase the risk of longer postoperative stay or higher mortality. Any observed effect on these outcomes in second fractures represents the influence of increasing age. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation of a traumatic fracture around a hip resurfacing arthroplasty using the proximal femoral locking compression plate.

We report on a 40-year-old man who sustained a traumatic extracapsular fracture of the proximal femur with a Birmingham Hip Resurfacing in situ. It was decided to retain the resurfacing implant and a proximal femoral periarticular locking compression plate (Synthes) was used to stabilise the fracture. The patient regained full range of pain-free movement, and was bearing his full weight on the operated leg by 18 weeks. He had a Harris Hip score of 90. Fractures around hip resurfacing arthroplasties are an emerging problem, and a literature review reveals two distinct modes of presentation i.e. 'atraumatic' and 'traumatic' fractures. We elaborate on these two different fracture patterns, with emphasis on the epidemiology, biomechanical considerations, and management strategies for the 'traumatic' type of periprosthetic fracture.

Spontaneous thigh compartment syndrome.

A young man presented with a painful and swollen thigh, without any history of trauma, illness, coagulopathic medication or recent exertional exercise. Preliminary imaging delineated a haematoma in the anterior thigh, without any fractures or muscle trauma. Emergent fasciotomies were performed. No pathology could be identified intra-operatively, or on follow-up imaging. A review of thigh compartment syndromes described in literature is presented in a table. Emergency physicians and traumatologists should be cognisant of spontaneous atraumatic presentations of thigh compartment syndrome, to ensure prompt referral and definitive management of this limb-threatening condition.

Does the place of fall influence the time to specialist treatment in patients sustaining hip fractures? A study of 4917 patients falling in four different settings.

Delay to treatment is a multifactorial issue for patients sustaining hip fractures. The place of fall could possibly impact on the time to specialist care. We aimed to investigate the correlation between the place where a hip fracture occurs, and the time to initiation of specialist fracture-specific treatment. We retrospectively analysed data that had been collected on 4917 consecutive hip fracture admissions to our unit. The recorded places of fall were divided into four groups, including those falling 'outside home', 'at home', 'residential or nursing home', and 'hospital inpatients' respectively. A 24-hour scale was used to record times of fall and of initiation of treatment. The latter was the time of admission to Accident & Emergency for groups 1-3, and the time of referral to the Orthopaedic team for group 4.23.5% patients fell outside their own home (group 1), and presented at only 2 hours post-injury. Patients in both group 2 (47.7%) and group 3 (23.6%) presented after 3 hours. Group 4 (4.9%) patients had to wait a median of 8 hours being referred to the Orthopaedic team. We found an interesting correlation between the place of injury and the delay in receiving treatment, in that those patients already receiving maximal healthcare attention, had to wait the longest to be referred to specialist care.

Telesurveillance of circular frame pin sites: one year's experience at a specialist unit.

Circular frame treatment for limb reconstruction involves repeated follow-up visits, and a substantial number of these appointments are for pin site review only. We have encouraged our frame patients to take photographs of their pin sites when they carry out their weekly dressing changes. The photographs are taken with mobile phones or digital cameras by the patients themselves, and the images sent to us by email. We reply within 24 hours, with either reassurance or appropriate instructions as indicated. In the past 12 months, five patients have had their pin sites reviewed remotely using this method, and have expressed a high level of satisfaction. These early results are encouraging.