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We reviewed 40 complex tibial non-unions treated with Taylor Spatial Frames. 39 healed successfully. Using the ASAMI scoring, we obtained 33 excellent, 5 good, 1 fair and 1 poor bone results. The functional results were excellent in 29 patients, good in 8, fair in two and poor in one. Mean patient satisfaction score was 95%. All but one patient would have the same treatment again. 28 of the 36 patients in work when injured, returned to work at the time of their final review. Four patients had an adverse event requiring significant intervention. Average treatment cost was approximately £26,000/patient. [ABSTRACT FROM AUTHOR]

Advanced Merkel Cell Carcinoma with intra — hepatic metastases in a reclusive gentleman is described. We present an interesting case with learning points and a review of this uncommon malignancy. [ABSTRACT FROM AUTHOR]

• Only around half of hospitals have dedicated protocols for the perioperative management of patients taking warfarin and DOAC medications. • Substantial variation in guidance exists among protocols of different hospitals with a lack of consistency in guidance within the Trauma Network. • A large proportion of protocols lacked guidance on several important aspects of management including type of anaesthesia during surgery. • Existence of dedicated hospital protocols did not improve attainment of the defined targets for time to surgery from admission. Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery. Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery. Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54–0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75–3.57, p=0.219). Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery. [ABSTRACT FROM AUTHOR]

Introduction: Due to their hypocoagulable state on presentation, anticoagulated patients with femoral fragility fractures typically experience delays to surgery. There are no large, multicentre studies previously carried out within the United Kingdom (UK) evaluating the impact of anticoagulant use in this patient population. This study aimed to evaluate the current epidemiology and compare the perioperative management of anticoagulated and non-anticoagulated femoral fragility fracture patients., Methods: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the United Kingdom. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Main outcomes under investigation included time to surgery, receipt of blood transfusion between admission and 48 h following surgery, length of stay, and 30-day mortality. These were assessed using multivariable linear and logistic regression, and Cox proportional hazards models. Only data from hospitals ≥90 % case ascertainment with reference to figures from the National Hip Fracture Database (NHFD) were analysed., Results: Data on 10,197 patients from 78 hospitals were analysed. 18.5 % of patients were taking anticoagulants. Compared to non-anticoagulated patients, time to surgery was longer by 7.59 h (95 %CI 4.83-10.36; p < 0.001). 42.41 % of anticoagulated patients received surgery within 36 h (OR 0.54, 95 %CI 0.48-0.60, p < 0.001). Differences in time to surgery were similar between countries however there was some variation across units. There were no differences in blood transfusion and length of stay between groups (OR 1.03, 95 %CI 0.88-1.22, p = 0.646 and 0.22 days, 95 %CI -0.45-0.89; p = 0.887 respectively). Mortality within 30 days of admission was higher in anticoagulated patients (HR 1.27, 95 %CI 1.03-1.57, p = 0.026)., Conclusions: Anticoagulated femoral fragility fracture patients comprise a substantial number of patients, and experience relatively longer delays to surgery with less than half receiving surgery within 36 h of admission. This may have resulted in their comparatively higher mortality rate. Inclusion of anticoagulation status in the minimum data set for the NHFD to enable routine auditing of performance, and development of a national guideline on the management of this growing and emerging patient group is likely to help standardise practice in this area and improve outcomes., Competing Interests: Declaration of competing interest Mr Will Eardley is the Surgical lead of the National Hip Fracture Database of England and Wales. The other authors declare no conflicts of interest., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Introduction: The age of those experiencing traumatic injury and requiring surgery increases. The majority of this increase seen in older patients having operations after accidents is in fragility proximal femur fractures (FPFF). This study designed a model to predict the distribution of fractures suitable for ambulatory trauma list provision based on the number of FPFF patients., Methods: The study utilized two datasets which both had data from 64 hospitals. One derived from the ORTHOPOD study dataset, and the other from National Hip Fracture Database. The model tested the predictability of 12 common fracture types based on FPFF data from the two datasets, using linear regression and K-fold cross-validation., Results: The predictive model showed some promise. Evaluation of the model with mean RMSE and Std RMSE demonstrated good predictive performance for some fracture types, although the r-squared values showed that large variation in these fracture types was not always captured by the model. The study highlighted the dominance of FPFFs, and the strong correlation between these and numbers of ankle and distal radius fractures at a given unit., Discussion: It is possible to model the numbers of ankle and distal radius fractures based off the number of patients admitted with hip fractures. This has great significance given the drive for increased day case utilisation and bed pressures across health services. While the model's current predictability was limited, with methodological improvements and additional data, a more robust predictive model could be developed to aid in the restructuring of trauma networks and improvement of patient care and surgical outcomes., Competing Interests: Declaration of competing interest The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

The current conflict in Afghanistan is characterised by significant injuries resulting from the use of Improvised Explosive Devices. Increasing survivability from battlefield injury, escalating musculoskeletal ballistic trauma and the use of blast weaponry combine to produce an injury profile which defines contemporary combat casualty care. Such complex multi-system trauma challenges current wound care rationale. Ballistic injury of the perineum, often associated with proximal femoral injury and significant tissue loss, raises particular management difficulties. These cases demand an individualised, flexible approach due both to the extent of their wounds, logistical issues with positioning and often limited surgical approaches. Routine positioning and approaches around the pelvis may not be available to the surgical team due to presence of external fixators and tenuous skin bridges. The availability of donor skin to cover soft tissue defects is limited and as such, approaches to wounds with minimal additional tissue trauma are of particular use. We describe the benefits of endoscopic techniques and equipment in the evaluation and management of such an injury.

Objectives: The role of Evidence Based Medicine in clinical care is to provide a framework for the integration of expertise, current evidence and the needs of the individual patient. Research presented at scientific meetings is an important source of such evidence, informing clinical decision making both on military operations and in home nation health care systems. The aim of this study is to review the levels of evidence presented at the Combined Services Orthopaedic Society (CSOS) and two other related scientific meetings., Methods: Retrospective review of abstracts presented at the annual scientific meetings of the CSOS, Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. Research abstracts were categorised according to the Centre for Evidence-Based Medicine's (CEBM) hierarchy of evidence. Statistical comparison was performed to investigate differences in evidence levels presented at each scientific meeting and between each year of the CSOS meeting., Results: 596 abstracts met the inclusion criteria for this study (179 CSOS, 173 SOMOS, 244 BTS). Level IV evidence accounted for the majority of presented abstracts at each meeting (72.6% CSOS, 69.4% SOMOS, 68.9% BTS). Level I evidence was uncommon at each meeting (6.1% CSOS, 5.2% SOMOS, 2.9% BTS). There was no statistical difference in the evidence levels presented at the three scientific meetings., Conclusions: The proportion of comparative clinical studies (Levels I-III) presented at military or trauma societies' scientific meetings reflects the difficulty of performing research in emergency surgery. This is further exacerbated in the military environment where operational commitments and delivery of care take priority. However, the future value of comparative clinical research in battlefield healthcare could have an enduring legacy that shapes trauma care for many decades.

Although mechanisms of modern military wounding may be distinct from those of ancient conflicts, the infectious sequelae of ballistic trauma and the evolving microbial flora of war wounds remain a considerable burden on both the injured combatant and their deployed medical systems. Battlefield surgeons of ancient times favoured suppuration in war wounding and as such Galenic encouragement of pus formation would hinder progress in wound care for centuries. Napoleonic surgeons eventually abandoned this mantra, embracing radical surgical intervention, primarily by amputation, to prevent infection. Later, microscopy enabled identification of microorganisms and characterization of wound flora. Concurrent advances in sanitation and evacuation enabled improved outcomes and establishment of modern military medical systems. Advances in medical doctrine and technology afford those injured in current conflicts with increasing survivability through rapid evacuation, sophisticated resuscitation and timely surgical intervention. Infectious complications in those that do survive, however, are a major concern. Addressing antibiotic use, nosocomial transmission and infectious sequelae are a current clinical management and research priority and will remain so in an era characterized by a massive burden of combat extremity injury. This paper provides a review of infection in combat wounding from a historical setting through to the modern evidence base.

Introduction: The management of complex extremity injury, which may require assessment of limb viability and performance of amputation, is a challenge to those involved in its emergent and definitive care. Concern exists regarding the exposure of orthopaedic trainees to such cases due both to changes in training and centralisation of trauma services., Subjects and Methods: This is a web-based observational study by survey, investigating the confidence and perceived adequacy of training of UK orthopaedic specialist trainees in the assessment of limb viability and amputation surgery. 222 responses from 888 trainees were required to achieve a < 5% error rate with 90% confidence; 232 surveys were completed., Results: Trainee confidence in dealing with the assessment of limb viability is high despite infrequent exposure to cases. The majority of trainees perceive their training in limb viability assessment as adequate. For performance of amputation, exposure is minimal, confidence is lower and 36% of trainees regard their training as inadequate., Conclusions: Limb viability assessment is an area in which trainees feel confident and well trained. There is, however, a perceived training inadequacy in amputation surgery and a corresponding lack of confidence for many trainees, irrespective of training year. This is the first study to offer an insight into specific training experiences of junior orthopaedic surgeons at a national level and it should drive the development of opportunities for trainees to develop skills in amputation surgery.

Introduction: Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected., Subjects and Methods: A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence., Results: A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a 'floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar., Conclusions: Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.

The nature of conflict is evolving, with current warfare being associated with an initial "shock and awe" phase followed by protracted periods ofcounter-insurgency and peace support missions. As conflict has changed, so have the munitions deployed and the resulting patterns of injury. Improvised Explosive Devices have become the preferred weapon of the insurgent and the resultant explosive and fragmentation injuries are the hallmark of modern military wounding. These injuries pose a significant challenge to deployed medical forces, requiring a well-defined, seamless approach from injury to rehabilitation. Traditionally, military medical services demonstrate a poor 'institutional memory' in the maintenance of combat surgical skills. Numerous publications detail the re-learning of key tenets of war surgery by generations of surgeons deploying onto the field of battle. While the maintenance of military surgical capability in trained surgeons may be addressed through combat surgical courses, concern exists as to the generic competency of those currently in training and their ability to deal with the burden of injury associated with modern conflict. The training of junior doctors in the United Kingdom and further afield is in a state of flux. New curriculum development, streamlined and run-through training programmes have combined with the legal requirements of the European Working Time Directive to produce a training landscape almost unrecognisable with that of previous years. This article investigates the development of current military wounding patterns and modern surgical training programmes. It describes processes already in place to address the unique training needs of military surgeons and proposes a framework for enabling appropriate training opportunities in the future.

Ninety-two retrospective cases of human bite injury referred to a Plastic Surgery department are presented. Particular emphasis is placed on the relationship of alcohol intake to these injuries, their distribution and subsequent management. A review of the literature is conducted. The human bite is a leisure time injury of the young single male in the North East. It has been shown that there is a clear link to alcohol and in particular weekend drinking. Prompt operative intervention and wounds located at the head and neck have been shown to be associated with a decreased risk of subsequent infection, which reflects findings in the earlier literature. Fifteen cases were infected. One was the result of a postoperative complication. The remainder were infected on admission. The majority of infected cases were upper limb bites and were associated with a delayed presentation.