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Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V

Performing anterior cruciate ligament (ACL) surgery in the immediate period after injury is controversial. However, there may be instances where the opportunity cost of delayed surgery for the patient may be unacceptable. Concomitant meniscus injuries may also prevent the patient from regaining range of motion in the preoperative period. Every week that surgery is delayed may increase pain and impair mobility for this group of patients. We investigate the functional and clinical outcomes in patients with ACL surgery in the immediate 3-week period following ACL injury. A cohort study was performed to compare the outcome of early ACL (less than 3 weeks after injury) and late ACL surgery (more than 3 weeks after surgery). A total of 58 patients were followed up at fixed time points over a 2-year period. Clinical measurements (range of motion and knee laxity scores) and functional outcome scores (International Knee Documentation Committee, Lysholm's Knee and Tegner's scores) were used to document outcomes over time. The mean time to surgery from the time of injury in the early ACL surgery group was 2 weeks (standard deviation [SD] = 0.45) and the 20 weeks (SD = 9.64) in the late ACL surgery group. The absence or presence of meniscal injuries had no significant effect on the improvement over time for both groups of patients (p > 0.05). Patients in the early ACL group had faster rates of improvement for clinical measurements and functional outcome scores but had started out initially with poorer outcomes at baseline. However, both groups had comparable outcomes (p > 0.05) at the 1- and 2-year mark postsurgery. Patients in both groups had no adverse outcomes. ACL Surgery within 3 weeks of injury (2 weeks SD = 0.45) is safe and has comparable outcomes compared to patients with delayed surgery (20 weeks SD = 9.64).

Purpose Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients. Methods A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria. Results Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes. Conclusion Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

Introduction Radial nerve palsies with humeral shaft fractures have historically been treated with expectant management. A previous systematic review by Shao et al, based on studies published from 1964 to 2004, purported no difference in the rate of recovery between patients treated with early surgical intervention versus expectant treatment. However, the authors combined expectant treatment to include patients treated nonsurgically and those with delayed surgery. To better understand the effect of surgery and its timing on radial nerve recovery, an updated analysis was performed with stricter treatment definitions. Methods An updated systematic review of the published literature was undertaken. An electronic database search was performed to identify publications that met specific inclusion criteria. A total of 23 articles published since 2000 met our eligibility requirements. Data were abstracted from these articles and analyzed in conjunction with the results of the systematic review by Shao et al. RESULTS:: The overall prevalence of radial nerve palsy was 12.3% (890/7,262). Patients with radial nerve palsy treated nonsurgically had a rate of spontaneous radial nerve recovery of 77.2%. Patients who failed nonsurgical management and underwent nerve exploration more than 8 weeks after their injury had a rate of recovery of 68.1%. Patients treated with early (within 3 weeks of the injury) surgical exploration and fracture repair had a rate of recovery of 89.8%. Discussion From the published data from 1964 to 2017, patients who underwent surgical exploration within 3 weeks of injury had a significantly higher likelihood of regaining radial nerve function than patients who underwent nonsurgical management with or without late surgical exploration.

Background The impact of delayed surgery on clinical outcomes after histologic or radiologic diagnosis of clinical stage I adenocarcinoma remains controversial. We evaluated the effects of delayed surgery on outcomes of patients with early-stage lung cancer. Methods Associations between time intervals of "histologic diagnosis-to-surgery" (HDS), "radiologic diagnosis-to-surgery" (RDS), and overall survival in clinical stage I adenocarcinoma were assessed using multivariable Cox proportional hazard analysis. Results A total of 561 consecutive patients with preoperative histologic confirmation of stage I lung cancer between 2006 and 2016 were included. Median time to HDS and RDS were 20 (2-267) and 58 (38-2,983) days. Higher Charlson comorbidity score, receiving brain magnetic resonance imaging screening, and video-assisted thoracoscopic surgery approach were significantly associated with increased risk of late HDS (>21 days). Smaller tumor size and non-radiologic solid-dominant pattern were significantly associated with increased risk of late RDS (>60 days). In the overall cohort, worse 5-year overall survival was associated with late HDS compared to early HDS (75.9% vs. 85.5%, P=0.003). No significant differences were found in later late vs. early RDS (83.7% vs. 83.3%, P=0.570). In 286 propensity-score matched patients, late HDS [adjusted hazard ratio (aHR) =2.031, P=0.038], higher Charlson comorbidity score (aHR=1.610, P=0.023), larger tumor size (aHR=2.164, P=0.031), without brain magnetic resonance imaging screening (aHR=2.051, P=0.045), and tumor with angiolymphatic invasion (aHR=4.638, P=0.001) were significantly associated with lower overall survival. Conclusions In patients with stage I lung adenocarcinoma, delayed surgery after a histologic diagnosis is an independent predictor of overall survival after adjusting for clinical risk factors, suggesting meaningful differences in clinical outcomes between timely vs. delayed surgeries.

Rectal cancer is the third most common types cancer in the world and rank second as a cause of cancer related deaths in 2018. Surgical is the main modality in treatment of rectal cancer, however preoperative radiotherapy significantly reduces local recurrence risk after surgery. At present there are two different schedules of preoperative radiotherapy, short-course preoperative radiotherapy (25 Gy at 5 fractions) followed by immediate surgery and long-course chemoradiotherapy (45-50 Gy at 25-28 fractions) followed by delayed surgery. Although the purpose and local control rate of both schedules is the same, it is indicated in different conditions.

BACKGROUND: There are multiple reports on the effect of time to surgery for geriatric hip fractures; it remains unclear if earlier intervention is associated with improved mortality, hospital length of stay (HLOS), or cost. METHODS: This was a multi-center retrospective cohort study. Patients (≥65y.) admitted (1/14-1/16) to six level 1 trauma centers for isolated hip fractures were included. Patients were dichotomized into early (≤24 h of admission) or delayed surgery (>24 h). The primary outcome was mortality using the CDC National Death Index. Secondary outcomes included HLOS, complications, and hospital cost. RESULTS: There were 1346 patients, 467 (35%) delayed and 879 (65%) early. The early group had more females (70% vs. 61%, p < 0.001) than the delayed group. The delayed group had a median of 2 comorbidities, whereas the early group had 1, p < 0.001. Mortality and complications were not significantly different between groups. After adjustment, the delayed group had no statistically significant increased risk of dying within one year, OR: 1.1 (95% CI:0.8, 1.5), compared to the early group. The average difference in HLOS was 1.1 days longer for the delayed group, when compared to the early group, p-diff

Objective To investigate differences in postoperative outcomes between short-course radiotherapy and delayed surgery (SCRT-delay) and chemoradiation (CRT) in patients with locally advanced rectal cancer (LARC). Background Previous trials suggest that SCRT-delay could serve as an adequate neoadjuvant treatment for LARC. Therefore, in frail LARC patients SCRT-delay is recommended as an alternative to CRT. However, data on postoperative outcomes after SCRT-delay in comparison to CRT is scarce. Methods This was an observational study with data from the Dutch ColoRectal Audit (DCRA). LARC patients who underwent surgery (2014-2017) after an interval of ≥6 weeks were included. Missing values were replaced by multiple imputation. Propensity score matching (PSM), using age, Charlson Comorbidity Index, cT-stage and surgical procedure, was applied to create comparable groups. Differences in postoperative outcomes were analyzed using Chi-square test for categorical variables, independent sample t-test for continuous variables and Mann-Whitney U test for non-parametric data. Results 2926 patients were included. In total, 288 patients received SCRT-delay and 2638 patients underwent CRT. Patients in the SCRT-delay group were older and had more comorbidities. Also, ICU-admissions and permanent colostomies were more common, as well as pulmonic, cardiologic, infectious and neurologic complications. After PSM, both groups comprised 246 patients with equivalent age, comorbidities and tumor stage. There were no differences in postoperative complications. Conclusion Postoperative complications were not increased in LARC patients undergoing SCRT-delay as neoadjuvant treatment. Regarding treatment-related complications, SCRT-delay is a safe alternative neoadjuvant treatment option for frail LARC patients.

Objectives: The paper presents the reconstructive options of the lower eyelid region in patients who have benefited from the excision of basal cell carcinomas. Methods: The study was based on the clinical and evolutionary particularities analyzed in a series of cases, the patients benefiting from excision and reconstruction for the treatment of basal cell carcinomas located at the level of the orbital region. Results: Following the surgical treatment, the local evolution was favorable with a good functional recovery. The aesthetic results were strongly influenced by the stage of the neoplasm, the final aspect being satisfactory for the patients included in the study. Conclusion: Early diagnosis and rapid and effective surgical treatment are associated with favorable results from a functional and aesthetic point of view. Delayed surgery and treatment of relapses are associated with increased risks and inferior results.

Aim: Laparoscopic inguinal hernia repair (LIHR) is gaining widespread acceptance, but its role in the management of incarcerated cases is not well outlined. This review analyses the outcomes of laparoscopic repair of incarcerated inguinal hernia in children. Patients and Methods: Literature was searched on PubMed® using terms 'laparoscopic', 'incarcerated', 'inguinal', 'hernia' and 'children'. Age, sex, side, sac content, operative technique, follow-up period, complication and recurrence rate were analysed. Results: Fifteen articles with 689 paediatric incarcerated inguinal hernias were identified between 1998 and 2018. Median age of patients was 22.4 months (2 weeks–16 years; M:F = 2.2:1). Side was mentioned in n = 576: n = 398 (69.1%) right and n = 178 (30.9%) left. In n = 355 (51.5%) manual reduction and delayed surgery (MRDS), in n = 34 (4.9%) manual reduction in general anaesthesia (MRGA) followed by emergency LHR and in n = 300 (43.5%) intraoperative reduction (IOR) was necessary. Incarcerated contents were documented in n = 68: intestine n = 36 (52.9%), ovary n = 14 (20.6%), omentum n = 11 (16.2%), appendix n = 5 (7.4%) and Meckel's diverticulum n = 2 (2.9%). Among the n = 18 girls in IOR group, n = 14 (77.8%) had ovaries incarcerated. For LHR, the hook method was used in 376 (54.6%) and purse-string suture in 313 (45.4%), with two conversions in IOR group. Mean followup was 15 months (3–80 months), with one (0.15%) testicular atrophy, and 4 (0.58%) recurrences in MRDS and 1 (0.15%) in IOR. All five cases were closed with pursestring technique. Total recurrence rate was 0.73%; significantly higher (P = 0.014) with pursestring (n = 5, 1.6%) than with the hook (none). Conclusion: Hook and purse-string methods are equally popular in LHR for paediatric incarcerated hernias, with 50% hernia reductions possible at the time of surgery. Recurrence rate is low and comparable with non-incarcerated hernias; however, it is significantly higher in purse-string method than hook technique.

Introduction The National Institute for Health and Care Excellence guidelines recommend a ‘fast-track’ approach to avoid preoperative biliary drainage (PBD) when treating resectable pancreatic cancer. For reasons not yet known, there is variable uptake of this approach across the UK. A ‘fast-track’ pathway which avoids PBD was introduced in University Hospitals Birmingham NHS Foundation Trust (UHB) and referring centres in 2015. Methodology Eleven semi-structured interviews were conducted with members of the hepatobiliary multidisciplinary team (MDT) in UHB and referring centres. Barriers and facilitators to pathway implementation were assessed. Results Facilitators underpinning implementation were collaboration between stakeholders, clinical leadership and careful coordination of referrals. Barriers to implementation included clinician opposition and increased workload. Barriers were mitigated through phased implementation and the appointment of dedicated staff. Conclusion Future work may focus on exploring contextual factors in other tertiary centres and evaluating the emotional impact of ‘fast-tracked’ versus delayed surgery in patients with resectable pancreatic cancer.

Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was &gt, 80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.

Summary: This study analyzed characteristics of hip fracture patients who did not undergo surgery within 24 hours after hospitalization, as recommended by the Belgian quality standards. Reasons for delay were analyzed. Delay in surgery for hip fracture was related to the medical condition of the patients. Introduction: To compare patients with optimal timing to patients with a delay in hip surgery, with respect to outcome (complications (postoperative) and mortality) and reasons for delay. Methods: A retrospective analysis of medical records compared patients operated on within 24h (Group A) to patients operated on more than 24h after admission (Group B). A follow-up period of 5 years after release or up to the time of data collection was used. Reasons for delay in relation with mortality were analyzed descriptively. Descriptive statistics were used for patient demographics and complications. Relationships causing a delayed surgery and mortality were analyzed using binary logistic regression. Additionally, a survival analysis was provided for overall mortality. Results: Respectively, 536 and 304 patients were included in Group A and B. The most prominent reason for delaying surgery was the patient not being medically fit (20.7%). Surgical delay was associated with more cardiovascular (p = 0.010), more pulmonary (p < 0.001), and less hematologic complications (p=0.037). Thirty-day mortality was higher with increasing age (p < 0.001), with hematologic (p < 0.001) or endocrine-metabolic complications (p = 0.001), and lower when no complications occurred (p = 0.004). Mortality at the end of data collection was higher for patients with delayed surgery (OR = 2.634, p < 0.001), an increased age (p = 0.006), male gender (p < 0.001), institutionalized patients (p = 0.009), pulmonary complication (p = 0.002), and having no endocrine-metabolic complications (p = 0.003). Survival analysis showed better survival for patients operated on within 24h (p < 0.001). Conclusions: Delayed surgery for patients with hip fractures was associated with bad additional medical conditions. Survival was higher for patients operated on within 24h of admission.

Background: Cataract is the leading cause of blindness globally. Many patients with cataract in developing countries delay to come for cataract surgery. Objectives: This study aimed to determine the factors associated with delayed uptake of cataract surgery among adult pa- tients seen at Mulago National Referral Hospital eye clinic in Uganda. Methods: Employing a hospital based cross-sectional study, adult patients with cataract and having moderate visual impair- ment or blindness were recruited. Patient-related factors for delayed surgery were assessed using a predetermined question- naire. Data was analyzed using stata version 14.2. Logistic regressions were used to determine the factors associated with delayed uptake of cataract surgery among these patients. Results: Eighty two participants with operable cataract were evaluated. Females were 44 (54%) and the mean age of partic- ipants was 67 years. Fifty three (65%) had delayed uptake of cataract surgery. The factors associated with delayed uptake of cataract surgery among patients with cataract were financial constraint, felt no need for surgery and good unilateral vision. Conclusions: Financial constraints, no felt need for cataract surgery and having good unilateral vision are the factors asso- ciated with delayed uptake of cataract surgery among cataract patients. We recommend cataract surgical outreach to remote areas and health education. Keywords: Risk factors; operable cataract; cataract; surgery; Uganda; sub-Saharan Africa.

Standard treatment for locally advanced oesophageal cancer is neoadjuvant chemoradiotherapy (nCRT), plus surgery 6-8 weeks later. Time to surgery (TTS) after nCRT seems safe up to 12 weeks, and possibly improves patient condition and pathological response. However, it is unknown whether prolonged TTS is safe in patients with residual disease. The aim of this study was to investigate whether prolonged TTS leads to inferior surgical outcomes and survival in patients with residual disease after nCRT. Methods Patients with pathologically confirmed residual disease 4-6 weeks after nCRT who underwent preoperative PET/CT and surgery were selected from the preSANO-trial and SANO-trial. Patients were stratified by TTS ≤12 weeks versus TTS >12 weeks after completion of nCRT. Primary endpoint was overall survival (OS). Secondary endpoints were progression-free survival (PFS), peroperative unresectability, microscopically radical resections (R0), tumour regression grade (TRG), postoperative complications and risk of distant dissemination. Effects of TTS on OS, PFS and distant dissemination were analysed with Cox regression, adjusted for Charlson comorbidity index (CCI) at baseline, as well as WHO performance score and weight loss after nCRT. Results Forty-two patients were included in the TTS >12 weeks and 132 patients in the TTS ≤12 weeks group. Median follow-up was 20.6 months (IQR 16.1-30.3). Adjusted hazard ratios for OS and PFS were 0.50 (95% CI: 0.24-1.02) and 0.47 (95% CI: 0.25-0.91), respectively, in favour of TTS >12 weeks. Patients with TTS >12 weeks had more postoperative complications (89% vs 72%, p = 0.049), but comparable peroperatively unresectable tumours (11.9% vs. 3.8%, p = 0.11), R0-resections (89% vs 87%, p = 0.89), and TRG-scores (p = 0.97) compared to patients with TTS ≤12 weeks. Patients with TTS >12 weeks showed less distant dissemination (HR 0.40, 95% CI: 0.18-0.88). Conclusion Prolonged TTS beyond 12 weeks in patients with clinically proven residual disease after nCRT did not have a negative effect on OS and on PFS, but was correlated with an increase in postoperative complications. The (non-significantly) better survival outcomes for TTS >12 weeks may be explained by the fact that patients had a lower risk of developing distant dissemination, which may reflect improved selection prior to surgery.

Introduction:The aim of this study was to evaluate whether delayed rectal cancer surgery after long-course neoadjuvant concomitant chemoradiotherapy was effective on pathological complete response (pCR), disease-free survival (DFS), and overall survival (OS).Methods:A total of 112 patients with rectal carcinoma diagnosed at the Radiation Oncology Clinic between 2011 and 2017 were retrospectively analyzed. We compared the outcomes of patients who were operated on greater than >9 weeks (delayed surgery) and less than

Background: Surgical management of Extradural Haematoma (EDH) in Closed Head Injury is an essential issue. Objective: The purpose of the present study was to compare the surgical outcome between early and delayed surgery of extradural haematoma (EDH) in closed head injury. Methodology: This comparative cross-sectional study was carried out from January 2010 to June 2011 for a period of one year and six months in the Department of Neurosurgery, Dhaka medical College Hospital, Dhaka, Bangladesh. All patients presented with traumatic head injury having extradural haematoma in any age with both sexes who were underwent surgical management were selected as study population. The patients were categorized into groups designated as group A or early surgery group where operation was done within 24 hours of head injury and group B or delayed surgery group where operation was done after 24 hours to 3 days of head injury. Inclusion of patients in group B was not intentional but due to delayed referral from primary and secondary hospitals of` different parts of' the country. Glasgow coma scale (GCS) was used for initial assessment and Glasgow outcome scale (GOS) was applied to assess outcome in terms of neurological recovery in all patients. General and neurological examinations and findings were recorded. Surgical outcome was noted and recorded in the data collection sheet. Result: Eighty (80) patients of traumatic head injury with EDH operation (EDH operated within 24 hours and after 24 hours of head injury) were enrolled in this study. Mean (±SD) age of the patients of group A and group B was 32.66±16.65 and 33.23±13.38 respectively. In this study the patient's age ranged from 3 years to 64 years. In group A, 6 patients were admitted with GCS (14-15) and 01 patient in group B. With GCS (9~13), 19 patients in group A and 22 patients in group B. With GCS (3-8), 15 patients were admitted in group A and 17 patients in group B. Out of all patients’ good recovery occurred in 80.0% in group A and 45.0% in group B. Moderate disability and severe disability in both group A and group B was 12.5% vs 30% and 7.5% vs 12.5% respectively. Furthermore 5.0% persistent vegetative state and 7.5% death occurred only among the patients of group B (p

Background and aim of the study Timing of surgery for infective endocarditis is controversial. The objective of this study was to report the outcomes of early vs delayed surgery (DS) of mitral endocarditis. Methods We retrospectively reviewed all patients treated surgically for mitral endocarditis between 2005 and 2016 in a single center. We analyzed midterm outcomes of early surgery (ES; surgery within 7 days or less of prior directed antibiotic treatment) in comparison to DS (surgery after more than 7 days of prior directed antibiotic treatment). Results Survival of all patients was 87% at one and 72% at 5 years. Mean follow-up time was 4.0 ± 3.1 years. Thirty-three (36.3%) patients were in the ES and 58 (63.7%) were in the DS group. Patients with ES were younger (47.4 vs 55.3 years), were in New York Heart Association class III or IV more frequently (97.0 vs 65.5%), and had higher EuroScore2 (15.6 vs 8.6%). The ES group had lower freedom from valve reoperation (98.2 vs 87.2%; P = .035) and the composite endpoint of >2 + regurgitation or reoperation at 5 years (98.2 vs 72.7%; P = .004). Conclusions ES was associated with a higher rate of reoperations and the composite endpoint of recurrent MR or reoperation.

It is well recognized that unplanned readmissions following total joint arthroplasty (TJA) are more prevalent in patients with comorbidities. However, few investigators have delayed surgery and medically optimized patients prior to surgery. In its current form, the Perioperative Orthopedic Surgical Home (POSH) is a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities.A total of 4188 patients who underwent TJA between January 2014 and December 2016 were retrospectively screened by the Readmission Risk Assessment tool (RRAT) score. one thousand one hundred and ninety four subjects had a preoperative RRAT score ≥3 and were eligible for inclusion. Patients were then separated into 2 cohorts based on whether they were enrolled into the POSH initiative (POSH; n = 216) or continued with surgery (non-POSH; n = 978) despite their risk.Since the implementation of the POSH initiative, patients with RRAT scores ranging from 3 to 5 have experienced lower 30-day (1.6% vs 5.3%, P = .03) and 90-day (3.2% vs 7.4%, P.05) readmission rates when compared to the non-POSH cohort. Only 15.3% of medically optimized patients enrolled in the POSH initiative were discharged to a post-acute care facility, whereas 23.4% of non-POSH patients were discharged to a post-acute care facility (P = .01). There were no differences in length of stay and infection rates between the 2 cohorts. Moreover, 90-day episode-of-care costs were 14.9% greater among non-POSH Medicare TJA recipients and 32.6% higher if a readmission occurred.The identification and medical optimization of comorbidities prior to surgical intervention may enhance the value of care TJA candidates receive. A standardized multidisciplinary approach to the medical optimization of high-risk TJA candidates may improve patient engagement and perioperative outcomes, while reducing cost associated with TJA.Level III, Retrospective Cohort Study.

Objectives Surgical drainage is the traditional mainstay of treatment of paediatric deep neck space infection (DNSI), but recently non-operative management in selected cases has been advocated. We sought to identify any characteristics predictive of requirement for surgical intervention. Design Retrospective cohort study using receiver operating characteristics analyses. Setting Tertiary referral paediatric hospital. Participants Children (≤16 years) with a radiologically confirmed diagnosis of retro- or parapharyngeal abscess over a ten-year period. Main outcome measures Predictive value of clinical and radiological variables in determining the requirement for surgical intervention. Length of hospital stay (LoS) was also examined. Results Ninety-three children were studied, 15 (16.1%) of whom underwent immediate surgery, 42 (45.2%) of whom underwent delayed surgery following an initial period of conservative management, and 36 (38.7%) of whom were managed conservatively. Age, WCC and CRP were not predictive of the need for surgical drainage. Radiological abscess diameter, however, was predictive of requirement surgery (AUC = 0.85 [95% CI ± 0.09] P = 0.02), with a cut-off value of 2.5 cm determined assuming equal weight to sensitivity and specificity. All DNSIs were successfully treated with no adverse outcomes, and there was no significant difference in LoS between groups. In those managed surgically, outcome and LoS did not depend on yield of pus. Conclusions Selected paediatric DNSIs can be successfully managed conservatively, with abscess diameter >2.5 cm a significant predictor of need for surgical intervention. Any benefit of surgery does not appear to depend on intra-operative yield of pus.

Importance Multiligament knee injuries are rare, but can lead to significant functional limitations. Surgery has been shown to improve outcomes, however, there remains considerable debate regarding the optimal timing of surgery. Objective We aimed to determine whether early surgery in the setting of a multiligamentous knee injury was associated with superior functional outcomes when compared with surgery on a delayed basis. Evidence review A comprehensive literature search of the MEDLINE, EMBASE and PubMed databases was conducted up to March 2018. We identified studies with a sample size greater than 10 that included subjects with an injury to at least two of the four major knee ligaments and compared outcomes between early and delayed surgery. We assessed the methodological quality of each included study using the Newstead-Ottawa Scale. Findings We identified 11 eligible studies, including a total of 320 patients (195 early and 125 delayed). The mean time to surgery among patients treated early was 11.2 days in comparison to 294.8 days for the delayed group. Early surgery was found to have a statistically significantly higher Lysholm score (p Conclusions and relevance Based on the current body of literature, which primarily consists of level IV evidence, early surgery in the setting of multiligament knee injury may provide better functional outcomes without compromising range of motion when using early postoperative mobilisation protocols. Further studies of higher quality are required to corroborate these findings. Level of evidence Level IV, systematic review.

Simple Summary Melanotic Neuroectodermal Tumor of Infancy (MNTI) is a very rare neoplasm that most commonly develops within maxilla in infants. It usually has a benign clinical course and is treated with only surgery. However, patients with large, inoperable, metastatic or multiply recurring MNTI may require systemic treatment. The role of pre- and post-surgery chemotherapy (CHT) in the management of MNTI is unclear. Here, we have presented the disease courses and outcomes of four infants treated with multidrug CHT due to inoperable/recurrent MNTI. Additionally, a systematic literature review was performed which revealed 38 similar cases in the last 42 years. Most children with primarily inoperable MNTI responded to CHT, which allowed physicians to perform complete, non-mutilating delayed surgery. However, it is still uncertain whether CHT administered after incomplete resection of MNTI prevents recurrence. This study aimed to contribute to the establishment of standards of management in patients with inoperable, metastatic or persistently recurring MNTIs, which are currently lacking. Abstract Melanotic Neuroectodermal Tumor of Infancy (MNTI) is a very rare pediatric neoplasm of neural crest origin. In most cases, it develops in infants as a localized tumor of the maxilla, and surgery is usually curative. In less than 10% of patients with inoperable, metastatic or persistently recurring MNTI, chemotherapy (CHT) may be considered; however, its role is still unclear. The aim of our study was to assess the efficacy of CHT in children with large, inoperable, metastatic and/or recurrent MNTI. Four such infants, treated with CHT in Polish and German centers of pediatric oncology, were presented. Additionally, a systematic literature search of the PubMed/MEDLINE, Scopus and Web of Science databases was performed, yielding 38 similar cases within the last 42 years. Neoadjuvant CHT, based mainly on the protocols for neuroblastoma, was often effective, allowing for complete delayed surgery in most cases. However, the role of adjuvant CHT in preventing recurrences after incomplete resection of MNTI remains unclear. Disseminated inoperable MNTI was almost universally associated with poor response to CHT and unfavorable outcome. Further investigations to elaborate standards of management in patients with inoperable, metastatic or persistently recurring MNTIs are necessary to improve outcomes.

Objective To analyze the factors of mortality in patients with acute adhesive small bowel obstruction (AASBO). Material and methods A retrospective multiple-center study included 143 (85.6%) patients with AASBO out of 167 consecutive patients with small bowel obstruction for the period 2017-2019. All patients were divided into 3 groups: early surgery group (within 12 hours after admission), late surgery (after 12 hours), non-surgical management group. The outcomes and Kaplan-Meier survival were compared in all groups. Results AASBO was resolved without surgery in 77 (53.8%) patients 19.6±17.4 (M=14) hours. In the Early Surgery Group (n=36), 24 patients had strangulation, 12 ones had non-strangulated bowel obstruction. In the Late Surgery Group (n=30), 15 patients had strangulation and 15 ones had no strangulation. Mortality was similar in early and late surgery (p=0.287), early and late surgery in patients with strangulation (p=0.940), early and late surgery in patients without strangulation (p=0.76). Patients died (n=10) after surgery only. Thus, postoperative mortality was 15.2%, overall mortality - 7.0%. All patients who underwent surgery after 24 hours (n=14) survived. Surgery increased the mortality risk compared to non-surgical management (95% CI 0 - 15.9, p=0.001). There was no effect of surgery time (more or less than 12 hours) on mortality for strangulation (95% CI 13.0-16.7, p 0.788) and non-strangulated obstruction (95% CI 29.4-5.4, p=0.061), bowel resection (95% CI 33.3-14.0, p=0.187), presence of bowel ischemia (95% CI 14.3-17.9, p 0.613). Conclusion Delayed surgery may be advisable in patients with AASBO and no obvious signs of strangulation due to less mortality.

Objective This study focuses on changes in gynecologic surgical activity at Hospital Foch, Paris, France during the first French COVID lockdown in 2020. Additional goals include the evaluation the extent of the postponement suffered for each type of surgery and estimate the possible negative impact for patients. Study design Single-center, retrospective, chart-review cohort study in the gynecology department of Hospital Foch. Comparison of all patients scheduled, postponed and operated during the first COVID lockdown (March 14, to May 11, 2020) versus the same period in 2019. Postponed surgeries were classified into 4 scheduling interval categories according to the Society of Gynecology Oncology (SGO) recommendations: urgent (without delay), semi-urgent (1-4 weeks), non-urgent (>4-12 weeks) and elective (>3 months) and evaluated to determine whether COVID-19-related delays of surgeries fell within guidelines. The potential "loss of chance" or medical risk associated with postponed surgeries was estimated according to a composite criterion including death, aggravation of expected tumor stages/grades in cancers, increase in surgical complexity compared to that initially planned, need for preoperative transfusions, start of morphine consumption during preoperative treatment for opiate-naive patients, additional hospitalization or consultations in emergency room and delay in treatment when surgery was urgent. Results During the 2020 French COVID lockdown, 61 patients had a surgical procedure and 114 were postponed; in the comparator 2019 group, 232 patients underwent surgical procedures, indicating an overall decrease of 65% of activity. Analysis of differences between the two years revealed a reduction of 64% in emergency procedures, 90% of functional pathologies, and 13% of cancers. According to SGO guidelines, the only type of surgical procedures that had excessive delay was the semi-urgent group, where time to surgery was 6.7 weeks [range 5.4-10 weeks] instead of the recommended interval of 1-4 weeks. Among postponed surgeries there were 10 patients (8.7%) with a potential "loss of chance" according to the composite criteria, all included in the semi-urgent group. Conclusion The COVID 19 pandemic was responsible for a significant decrease of activity in the surgical department of Hospital Foch. Difficulty of rescheduling surgeries was responsible for an increased delay in semi-urgent operations. In almost 9% of postponed surgeries, there was a potential "loss of chance", which likely represents only the tip of iceberg of collateral damages due to COVID 19 pandemic in this surgical unit. These data show the importance of continuing to treat pathologies requiring urgent or semi-urgent surgery during pandemics.

BACKGROUND: To evaluate and compare the natural history and growth kinetics of sporadic clear cell renal cell carcinoma (ccRCC) with those of ccRCC in von Hippel-Lindau disease (VHL). METHODS: Sixty patients in the sporadic group with 61 tumors and 15 patients in the VHL group with 30 tumors whom all underwent delayed surgery after at least 12 months of active surveillance (AS) were enrolled to conduct a retrospective cohort study. The growth rate was calculated, and the growth kinetics between the sporadic and VHL groups were compared. The patient and tumor characteristics were reviewed, and their correlation with growth rate was analyzed. RESULTS: The mean growth rate of sporadic ccRCC was 0.91 cm/year (ranging from 0–4.74 cm/year) and that of VHL ccRCC was 0.47 cm/year (ranging from 0.04–1.89 cm/year). The growth rate of sporadic ccRCC showed a tendency of being faster than that of VHL ccRCC but did not reach statistical significance (P=0.07). The factors affecting the growth rate were different between the two groups. For VHL ccRCC, the only factor that correlated with growth rate was initial tumor diameter (P

Pancreatoblastoma (PBL) is a rare malignant epithelial neoplasm affecting typically young children. Signs related to advanced upper-abdominal tumor accompanied by elevated serum α-fetoprotein levels in a young child suggest PBL, however histopathological examination is required for diagnosis. The mainstay of treatment is a complete surgical resection. Inoperable and/or metastatic PBL may become amenable to complete, delayed surgery after neo-adjuvant chemotherapy. This manuscript presents the internationally consensus recommendations for the diagnosis and treatment of children with PBL, established by the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) within the EU-funded PARTNER (Paediatric Rare Tumors Network – European Registry) project.

The study by Andren et al. provides substantial results illustrating better survival rates in the iNPH subjects with early shunt surgery in comparison to those with delayed surgery [1]. I sincerely appreciate the authors for publishing the results of this valuable study. However, I believe that there may be some points to be discussed for a better understanding of the results of this study.

Background Deferral of surgeries due to COVID-19 has negatively affected access to elective surgery and may have deleterious consequences for patient’s health. Delays in access to elective surgery are not uniform in their impact on patients with different attributes. The objective of this study is to measure the change in patient’s cost utility due to delayed elective cholecystectomy. Methods This study is based on retrospective analysis of a longitudinal sample of participants who have had elective cholecystectomy and completed the EQ-5D(3L) measuring health status preoperatively and postoperatively. Emergent cases were excluded. Patients younger than 19 years of age, unable to communicate in English or residing in a long-term care facility were ineligible. Quality-adjusted life years attributable to cholecystectomy were calculated by comparing health state utility values between the pre- and postoperative time points. The loss in quality-adjusted life years due to delayed access was calculated under four assumed scenarios regarding the length of the delay. The mean cost per quality-adjusted life years are shown for the overall sample and by sex and age categories. Results Among the 646 eligible patients, 30.1% of participants (N = 195) completed their preoperative and postoperative EQ-5D(3L). A delay of 12 months resulted in a mean loss of 6.4%, or 0.117, of the quality-adjusted life years expected without the delay. Among patients older than 70 years of age, a 12-month delay in their surgery corresponded with a 25.1% increase in the cost per quality-adjusted life years, from $10 758 to $13 463. Conclusions There is a need to focus on minimizing loss of quality of life for patients affected by delayed surgeries. Faced with equal delayed access to elective surgery, triage may need to prioritize older patients to maximize their health over their remaining life years.

The optimal treatment of locally advanced rectal cancer with synchronous liver metastases remains controversial. In this study, we aimed to evaluate the safety, efficacy, and oncologic outcomes of upfront chemotherapy and short-course radiotherapy with delayed surgery in patients with locally advanced rectal cancer and synchronous liver metastases.Forty-four patients who underwent upfront chemotherapy and short-course radiotherapy with delayed surgery for locally advanced rectal cancer (cT3/4,2.0 mm from the mesorectal fascia) with synchronous liver metastases between January 2010 and June 2017 were reviewed retrospectively. Primary and metastatic liver lesions were resected with curative intent. Upfront chemotherapy and short-course radiotherapy were administered. Thereafter, restaging, surgery only, or additional chemotherapy followed by surgery was performed.At the time of initial diagnosis, 20 patients had3 liver metastases; 24 patients had ≥3 liver metastases. Twenty-three patients had hemi-liver metastases; 21 patients had bilobar liver metastases. R0 resection of rectal lesions was achieved in 43 patients. Synchronous R0 resection of liver metastases was achieved in 41 patients. Postoperative complications (Clavien-Dindo Grade ≥ III) were noted in 5 patients. Grade 3/4 adverse events were observed in 26 patients. All adverse events were managed effectively with medication and supportive care. The 3-year overall survival and progression-free survival rates were 65.3% and 26.9%, respectively.Upfront chemotherapy and short-course radiotherapy with delayed surgery appear to be safe and effective in patients with locally advanced rectal cancer and synchronous liver metastases without substantially increasing treatment induced morbidity.

Background To determine an optimized treatment protocol during the COVID-19 epidemic for patients with closed fracture and delayed surgery. Methods The epidemic data of three hospitals, randomly selected from different administrative regions of Wuhan, were analyzed retrospectively from 23 January to 31 March 2020. Changes in the number of confirmed cases per day (cumulative and new) of each region were tracked as a reflection of changing epidemic risk levels. The risk level map was drawn. The epidemic status, treatment protocols, and treatment efficiencies for patients with closed fracture in the three hospitals were compared. Results Overall, 138 patients with closed fracture were admitted. Each hospital had established its own protocol, according to the initial perceived risk. Based on the risk level map, over the study period, the risk levels of the three regions changed independently and were not in sync. All patients recovered and were timely discharged. No staff member was detected with COVID-19. Conclusions The COVID-19 risk level of each area is dynamic. To optimize medical resources, avoid cross-infection, and improve efficiency, changes in epidemic risk should be monitored. For patients with closed fracture, treatment protocols should be adjusted according to changes in epidemic risk.

This study was designed to compare and analyse the amount of packed red blood cell transfusions (PRBCTs) in relation to surgical timing in elderly patients undergoing cephalomedullary nailing due to intertrochanteric fractures.A total of 110 patients (24 men, 86 women) who had received cephalomedullary nailing for intertrochanteric fractures were retrospectively investigated. A restrictive transfusion strategy was followed during the peri-operative period. Patient characteristics and fracture classifications, methods of anaesthesia, time interval from admission to surgery (TI) and operative duration (OD) were investigated. The amount of PRBCTs was measured and categorised as pre-operative, post-operative and entire peri-operative values. The patients were divided into early surgery (ES) and delayed surgery (DS) groups based on surgical treatment within or after 48 h of admission. In addition, multiple regression analysis including TI and other factors likely to affect blood loss and PRBCT was conducted to objectively evaluate the impact of TI on the amount of the entire peri-operative PRBCT.The patients had a mean age of 82.6 years (range, 68-98), mean TI of 41.1 h (range, 5-110) and mean OD of 37 min (range, 15-90). Although the amount of pre-operative PRBCT was significantly different between the ES and DS groups (36.2 ml vs. 168.3 ml, p0.001), they displayed no remarkable difference regarding post-operative and the entire peri-operative amount of PRBCTs (279.7 ml vs. 189.8 ml, p = 0.064 and 315.9 ml vs. 358.0 ml, p = 0.992, respectively). The results from multiple regression analysis demonstrated that TI did not significantly affect the amount of the entire peri-operative PRBCT.If an appropriate transfusion strategy is adopted, TI does not seem to affect the amount of peri-operative PRBCT in elderly patients with intertrochanteric fractures. Nevertheless, careful transfusion management with a view to compensating for any drop in pre-operative haemoglobin is necessary when surgery is delayed.

Our objective was to investigate the management of patients with asymptomatic suspicious thyroid nodules ≤1 cm.We retrospectively reviewed medical records of patients with sonographically suspicious thyroid nodules ≤1 cm and without distant metastases, suspicious lymph node metastasis (LNM), or extrathyroidal extension (ETE).Of the 386 enrolled patients, 174 (45.1%) had immediate surgery (IS), while 212 (54.9%) underwent active surveillance (AS). In the IS group, 166 (95.4%) patients were confirmed as having papillary thyroid microcarcinoma. LNM and ETE were observed in 24.7% and 2.4% cases, respectively. In the AS group, nodule size increased by ≥3 mm in 11 (5.2%) patients and 39 (18.4%) had a50% increase in nodule volume after a median follow-up of 12 months. Nodules with smaller volume at diagnosis were more likely to increase in volume later. Newly suspicious LNM was detected in 23 (10.8%) patients. Delayed surgery (DS) was performed in 101 patients, with 27 showing disease progression. ETE and LNM were detected in 3% and 36%, respectively, of patients with papillary thyroid microcarcinoma. Compared with IS, tumors in the DS group more frequently showed lateral LNM and capsular invasion (P.05). No patient had recurrence or died of thyroid cancer during postoperative follow-up (median 26 [4-60] months).IS or DS of patients with asymptomatic suspicious thyroid nodules ≤1 cm was relatively high in China. The inertia of low-risk nodules and the effectiveness of DS for those that progressed make AS a feasible strategy.

Objective The endpoint of the present study was to evaluate the outcomes of short-course radiotherapy (SCRT) and SCRT with delayed surgery (SCRT-DS) on a selected subgroup of frail patients with locally advanced middle/low rectal adenocarcinoma. Methods From January 2008 to December 2018, a total of 128 frail patients with locally advanced middle-low rectal adenocarcinoma underwent SCRT and subsequent restaging for eventual delayed surgery. Rates of complete pathological response, down-staging, disease free survival (DFS) and overall survival (OS) were analyzed. Results 128 patients completed 5 × 5 Gy pelvic radiotherapy. 69 of these were unfit for surgery; 59 underwent surgery 8 weeks (average time: 61 days) after radiotherapy. Downstaging of T occurred in 64% and down-staging of N in 50%. The median overall survival (OS) of SCRT alone was 19.5 months. The 1-year, 2-year, 3-year and 5-year OS was 48%, 22%, 14% and 0% respectively. In the surgical group, the median disease-free survival (DFS) and median OS were, respectively, 67 months (95% CI 49.8–83.1 months) and 72.1 months (95% CI 57.5–86.7 months). The 1, 2, 3, 5-year OS was 88%, 75%, 51%, 46%, respectively. Post-operative morbidity was 22%, mortality was 3.4%. Conclusions Frail patients with advanced rectal cancer are often “unfit” for long-term neoadjuvant chemoradiation. A SCRT may be considered a valid option for this group of patients. Once radiotherapy is completed, patients can be re-evaluated for surgery. If feasible, SCRT and delayed surgery is the best option for frail patients.

Background The objective of this study was to determine if there is an impact of surgical delay on 5-year overall survival (OS) from early stage colon cancer, and if so, to define how long surgery can safely be postponed. Methods Using the NCDB, we compared early (14–30 days) and delayed surgery (31–90 days) in patients with Stage I/II colon cancer. Outcomes included OS at five years and odds of death. Results Delayed resection conferred a decreased 5-year OS of 73.0% (95% CI, 72.6–73.4), compared to early resection 78.3% (95% CI, 77.9–78.8). When time to surgery was divided into one-week intervals, there was no difference in the odds of death with delay up to 35–41 days (6 weeks), but odds of death increased by 9% per week thereafter. Conclusions These data support that definitive resection for early stage colon cancer may be safely delayed up to 6 weeks., Highlights • It is unknown if resection can be safely delayed in patients with early stage colon cancer. • Retrospective analysis of 107,774 stage I/II colon cancer patients divided into early (14–30 days) versus delayed (31–90 days) cohorts. • Delayed resection conferred a decreased 5-year OS (73.0%) compared to early resection (78.3%). • Odds of death for each additional week of delay did not differ up to 6 weeks, but increased by 9% per week thereafter.

Purpose: To estimate survival curves in patients with hip fracture according to gender, age, type of fracture, and waiting time for surgery and to compare them with the life expectancy of the general population. The study hypothesis is that survival after hip fractures is significantly lower than in the general population, especially in cases that underwent delayed surgery, regardless of age and gender. Methods: A survival analysis study was designed and approved by our institutional ethics review board. All patients who were coded with a diagnosis of hip fracture from 2002 to 2018 were included in the study. A total of 1176 patients were included, and the median age was 81 years (18–105 years). Kaplan-Meier curves and log-rank tests were performed to compare survival curves between those who underwent surgery on time and those with surgical delays. An exponential multivariate regression model was estimated, and a hazard ratio (HR) was reported for age, gender, and wait time for surgery. A significance of 5% was used, and a confidence interval level of 95% was reported. Results: The Kaplan-Meier curves for delayed surgery (log-rank, p = 0.00) and the age group (log-rank, p = 0.00) were significantly different. Exponential regression estimated an HR 1.05 (1.05–1.07) for age, HR 1.80 (1.51–2.13) for men, and HR 1.93 (1.61–2.31) for each day of wait for surgery. Conclusions: The 2 significant findings of this study are that hip fracture patients over 40 years old have a higher risk of dying at any time compared to the general population and that the waiting time for surgery (a modifiable factor) decreases survival rates at any time.

Purpose Unicameral bone cysts (UBCs) are most often found when accompanied by a pathological fracture. In these cases, the doctor must determine the optimal timing for the surgery. The purpose of this study was to evaluate the outcome of immediate surgery as compared with delayed surgery in paediatric pathological fractures due to UBCs. Methods This retrospective study assessed the medical records of 65 patients between January 2012 and September 2016. Group A included 34 patients who underwent immediate surgery, including curettage, demineralized bone matrix and fixation with elastic stable intramedullary nailing. Group B included 31 patients who underwent the same surgery several months later. The outcome evaluations included the radiological changes, brace fixation time, cyst healing time, at the first-, third- and sixth month, and final visit. Results The mean brace fixation time was 26.3 days (sd 5.7) for group A and 53.8 days (sd .1) for group B (p = 0.012). According to radiological evaluations, 3/34 patients in group A and 5/31 in group B had recurrence after the first surgery. A second surgery was performed in all cases of recurrence, and all fractures were healed at the last visit. There was no significant difference in the recurrence rate between the two groups (p = 0.4631), and healing times were also similar (p = 0.6033). Conclusion Both the immediate and delayed surgery were safe for the treatment of UBCs with fractures. We suggest immediate surgery for shorter fixation time and early activity. Level of evidence IV

Early hip fracture surgery is recommended to decrease the morbidity and mortality. The extent to which such guidelines are being followed in developing countries like India is unknown. About 20% of the patients presented to hospital after 24 hours of injury, and only one-third had surgery within 48 hours of presentation. Early hip fracture surgery is recommended to decrease the morbidity and mortality following hip fractures. Understanding the factors responsible for delay in surgery is important to improve the quality of hip fracture care. This study was conducted to study the factors causing delay in elderly hip fracture surgery in India. In this prospective study, 272 consecutive hip fracture surgeries at a single hospital were included. Delayed surgery was defined as when the time to surgery (reaching hospital to start of incision) was more than 48 hours. Additionally, the total time to surgery (including time taken for patients to reach hospital after injury) was studied. Factors associated with delayed surgery were assessed using regression models. Eighty-seven (32%) patients had a surgery within 48 hours of presentation. Majority of the patients had a delay (82%, N = 151/185) due to one or more medical reasons. Fifty-four (20%) patients presented to hospital after 24 hours of injury. The mean total time to surgery was 112 ± 90 hours with time after reaching hospital contributing to 78% of the total time. Multiple comorbidities (odds ratio, OR = 3.47 [1.42–8.45]), fall as mode of injury (OR = 3.54 [1.61–7.80]), requiring an additional investigation (OR = 10.4 [3.4–31.81]), and requiring arthroplasty (OR = 40.57 [7.01–234.97]) were independently associated with delayed surgery. Only about one-third of the patients received surgery within 48 hours of reaching the hospital, and about 20% of the patients presented to hospital after 24 hours of injury. Delayed surgery was primarily due to medical comorbidities. Hospitals should establish protocols to ensure faster optimization of patients.

AIM AND SCOPE Our standard management is to operate isolated sagittal synostosis around 4 months of age because of morphological and cognitive outcomes. However, some patients present late and the likelihood of spontaneous remodeling is low in isolated sagittal craniosynostosis operated on after 12 months of age with a limited technique. The preliminary result of a modified technique for forehead remodeling and subtotal calvarial remodeling in nonsyndromic scaphocephalic children with late presentation is presented. PATIENTS AND METHODS All patients older than 1 with isolated sagittal synostosis assessed between 2011 and 2015, over 1 year of age at the time of surgery, with available pre and postoperative computed tomography-scans, were retrospectively included into the study. The following parameters were collected: (1) age at surgery, (2) duration of the procedure, (3) surgical technique, (4) fronto-nasal angle before and after surgery and (5) forehead width before and after surgery. RESULTS Ten patients aged between 15 months and 6 years were retrospectively included. Delayed surgery was due to late presentation or initial parental reluctance. All patients presented with a transversal narrowing of the forehead and an anterior bulge. Mean age at surgery was 28 months and mean follow up was 23 months (1-4 years). Measurements showed significant improvement of both the fronto-nasal angle and the width of the forehead. CONCLUSIONS Late-presenting scaphocephalic patients operated on after 12 months of age require forehead remodeling to achieve satisfactory aesthetic results. Modified forehead remodeling by splitting the forehead sagittally into 2 symmetrical halves and adding a midline bone strip is a safe and feasible way to widen the forehead. Long term follow-up is needed to assess this modified technique.