Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure. Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months. Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion. Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

This is a retrospective case review of 237 patients with displaced fractures of the acetabulum presenting over a ten-year period, with a minimum follow-up of two years, who were studied to test the hypothesis that the time to surgery was predictive of radiological and functional outcome and varied with the pattern of fracture. Patients were divided into two groups based on the fracture pattern: elementary or associated. The time to surgery was analysed as both a continuous and a categorical variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. For elementary fractures, an increase in the time to surgery of one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When time was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. The organisation of regional trauma services must be capable of satisfying these time-dependent requirements to achieve optimal patient outcomes.

Reduction of rerupture and surgery risks may be possible using dynamic ultrasound case selection. Further studies are needed to show whether functional results are the same with surgical and nonsurgical treatment when dynamic ultrasound criteria are used for case selection.

Summary Background Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. Methods National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009 and 18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received. The care of a stratified random sample of 54 women who died during or up to a year after the end of pregnancy between 2009 and 18, (18 from the aggregated group of Black women, 19 from the Asian aggregated group and 17 from the White aggregated group) was re-examined specifically to describe any structural or cultural biases or discrimination identified. Findings There were no major differences causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). Interpretation This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. Funding This research is funded by the (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217–21,202. MK is an NIHR Senior Investigator. SK is part funded and FCS fully funded by the (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.