Benjamin John Ollivere

Aims: Fracture-related infection (FRI) is a major cause of morbidity following limb fracture surgery. Topical vancomycin has gained popularity as an adjunct to systemic prophylaxis; however, concerns regarding nephrotoxicity, impaired bone healing, and wound complications remain. This review aims to evaluate the efficacy and safety of intraoperative topical vancomycin powder in preventing FRI in patients undergoing surgical management of upper or lower limb fractures. Methods: A systematic review of randomized controlled trials (RCTs) was conducted in February 2026. Comprehensive searches of Medline, EMBASE, and Cochrane CENTRAL were performed. Trials were included if they randomized patients with limb fractures between intraoperative topical vancomycin powder and no vancomycin, placebo, or standard care. The primary outcome was FRI or deep surgical site infection (SSI). Secondary outcomes included time to FRI, organism profile, antimicrobial resistance, superficial SSI, nonunion, revision surgery, wound healing problems, renal impairment, and other reported complications. Results: Five studies involving 1,373 patients were included. Topical vancomycin significantly reduced FRI rates compared with controls (risk ratio (RR) 0.64 (95% CI 0.43 to 0.96); p = 0.030). A significant reduction in FRIs caused by gram-positive organisms was identified in patients given topical vancomycin (RR 0.41 (95% CI 0.24 to 0.71); p = 0.001). No differences in FRIs caused by gram-negative or resistant organisms were identified. There were no significant differences in superficial SSI, nonunion rates, wound healing, or other complications. Topical vancomycin was not associated with a significant risk of nephrotoxicity. Conclusion: Topical vancomycin powder may be a safe and effective adjunct to standard systemic prophylaxis for preventing FRI, particularly in reducing gram-positive infections. However, current evidence is limited by a lack of high-quality RCTs and small sample sizes. A large, definitive RCT is needed to determine the efficacy, safety, and cost-effectiveness of topical vancomycin in limb fracture surgery. Cite this article: Bone Jt Open 2026;7(10):1253–1260.

Aims: This study aimed to assess the association between surgical delay due to non-medical reasons and one-year mortality in patients with hip fracture, and to explore whether a dose-response relationship exists between increasing time to surgery and mortality risk. Methods: A retrospective cohort analysis was performed using prospectively collected data from the Nottingham Hip Fracture Database. A total of 5,414 patients aged ≥ 60 years admitted with a fragility femoral fracture to a major trauma centre between April 2016 and March 2023 were reviewed. Time to theatre was measured from emergency department arrival to anaesthetic start. Delays beyond 36 hours were categorized as either medical or logistical. The primary outcome was all-cause one-year mortality with a secondary outcome being length of stay (LOS). Multivariable Cox proportional hazards models were used to assess associations, adjusting for age, sex, comorbidity, and cognition. Results: Of the cohort, 38.5% (n = 2,083) experienced surgical delay beyond 36 hours; 27.5% (n = 1,490) due to limited surgical capacity and 11.0% (n = 593) due to medical unfitness. After adjusting for age, sex, comorbidity, and cognition, delay due to logistical factors was associated with a 20% increase in one-year mortality (hazard ratio (HR) 1.20 (95% CI 1.06 to 1.36); p = 0.004). A secondary analysis excluding medically unfit patients demonstrated a stepwise increase in hazard with increasing time to theatre, suggesting a dose-response effect. LOS was also increased with delay to theatre by one day in this cohort. Conclusion: Delayed surgery beyond 36 hours, due to lack of surgical capacity, is independently associated with increased mortality following hip fracture. These findings reinforce the need for protected surgical capacity and prioritization of prompt surgery to improve outcomes in this vulnerable population. Cite this article: Bone Joint J 2026;108-B(8):1021–1028.

Early recovery after surgery in frailty and hip fracture: where are we now?

Distal radius fractures (DRFs) are one of the most common orthopaedic injuries seen in the Accident and Emergency (A&E) Department, accounting for 17% of all fractures. They are associated with significant morbidity, with substantial economic and societal costs due to the high incidence of these injuries. Initial management of displaced fractures consists of prompt reduction of the fracture in A&E and application of a moulded plaster cast to hold the fracture. However, there is currently no consensus on the best anaesthetic to use during the manipulation procedure. The most frequently used are local anaesthetic techniques, namely haematoma block and Bier’s block. Current UK guidelines recommend the use of intravenous local anaesthetic (Bier’s block) for manipulation. However, surveys of national practice show significant variations in practice, with haematoma block being the most commonly used technique. This article summarises the current evidence regarding the anaesthetic techniques for performing wrist manipulations.

Aims: Fragility hip fractures are a growing concern, increasing year on year by just over 1%. These injuries carry high mortality rates and often result in poor functional outcomes, especially in frail patients. Early mobilization after surgery has been linked to better survival and shorter hospital stays. While Enhanced Recovery After Surgery (ERAS) protocols are well established in elective orthopaedics, their application in hip fracture care remains limited due to the frailty of this patient group. Methods: The Cardiac Chair Position (CCP), originally used in cardiac surgery, may support early mobilization by helping patients transition from supine to standing. This study evaluated the impact of incorporating CCP into day 1 rehabilitation for hip fracture patients. This observational cohort study compared two six-month periods: June to November 2019 (standard care) and June to November 2021 (standard care plus CCP). A total of 270 patients aged 65 years and older with neck of femur fractures from low-energy trauma were included. Results: Patients were divided into two groups: those who received standard bed exercises, and those who also used the CCP. Researchers collected data on day 1 mobility, postural hypotension, inpatient mortality, 30-day survival, length of hospital stay, and discharge destination. No significant differences were observed in postural hypotension, mortality, length of stay, or discharge destination. However, the CCP group showed significantly improved day 1 mobility with an increased proportion of patients demonstrating the ability to push-off the bed, stand and step, transfer to a chair, and walk. Conclusion: Although CCP did not affect survival or hospital stay, it did enhance day 1 mobility. Given its simplicity, CCP is a promising addition to hip fracture rehabilitation. Further studies, including randomized trials and cost-effectiveness assessments, are needed to confirm its broader benefits. This research underscores the importance of early mobilization in elderly patients with fragility fractures. Cite this article: Bone Jt Open 2026;7(1):47–53.

Introduction: The optimal surgical approach for intraarticular calcaneal fractures remains debated. This study compares deep infection rates between the extended lateral (EL) and sinus tarsi (ST) approaches. Methods: A retrospective review was conducted of 782 patients treated surgically for OTA 82B/C calcaneal fractures across 15 institutions. Deep infection was defined as requiring surgical débridement or treatment for osteomyelitis. Risk factors were identified using univariate and multivariate analyses. Results: Of 782 fractures, 444 were treated with EL and 338 with ST. Deep infections occurred in 6.8% of EL and 3.0% of ST cases ( P = 0.017). Multivariate analysis found that surgical approach ( P = 0.03) and age ( P < 0.001) were independent risk factors. EL had more wound complications; ST had more symptomatic implants. Conclusion: The ST approach was associated with lower rates of deep infection and wound complications, even in higher-risk patients.

Aims: It is unclear if a supportive bandage, removable splint, or walking cast offers the best outcome following low-risk ankle fractures in children. The aim of this study was to evaluate the feasibility of a randomized controlled trial to compare these treatments.Methods: Children aged five to 15 years with low-risk ankle fractures were recruited to this feasibility trial from 1 February 2020 to 30 March 2023. Children were randomized to supportive bandage, removable splint, or walking cast for two weeks. Follow-up at two, six, and 12 weeks was undertaken to determine feasibility for a definitive trial. Outcomes collected included complications, the Patient-Reported Outcomes Measurement Information System (PROMIS) mobility score, Paediatric Quality of Life Inventory, youth version of the EuroQol five-dimension health questionnaire, and Activities Scale for Kids - Performance.Results: A total of 87 children from six hospitals were randomized at a rate of 0.9 participants per site per month. Two children in the supportive bandage group crossed over to an alternative device. Complications were reported in six children. One child in the cast group developed skin blisters. One child in cast and one in bandage sustained a reinjury during the 12-week follow-up, and two children (one splint and one cast) required additional immobilization after the two-week treatment for persistent pain. Of the 84 participants who remained in the study at six weeks, 43 (51.2%) returned follow-up questionnaires at six weeks. Of the patient-reported outcome measures (PROMs), proxy-reported PROMIS mobility showed good responsiveness, low ceiling effects, and low missing item rates. In an exploratory analysis, small differences were observed between groups, with no evidence that any of the treatments were superior.Conclusion: This feasibility study showed acceptable recruitment and retention rates. There remains equipoise regarding the best treatment of these injuries. All three treatments appear well tolerated with similar complication rates. A primary outcome of complications or treatment failure would provide the highest study retention with secondary PROMs and economic analysis.Cite this article: Bone Joint J 2025;107-B(1):108–117.

Integrating mental health into major trauma care