Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

A systematic review, following strict inclusion criteria, identified 32/48 low and 16/48 high-performance runners with stress fractures of the femoral neck. Surgical treatment was performed in 33/48 cases and was significantly higher (p = 0.009) in high-performance runners. Among the 28/48 runners who resumed running, there were significantly more lower-performance runners (23/32) than higher-performing runners (5/16) (p = 0.012) and significantly more non-displaced (22/30) than displaced fractures (6/18) (p = 0.014). Complicated cases showed significantly less favourable follow-up results (p = 0.036). A significantly shorter (p = 0.032) diagnostic time for evaluation occurred with a previous history of a stress fracture or a relevant comorbidity. Stress fractures of the femoral neck represent an incisive incident for runners, and early consideration in the differential diagnosis of hip pain is required to avoid potential long-term sequelae and suboptimal function.

Background: Posterolateral tibial plateau shear fractures often require buttress plating, which can be performed through a posterolateral approach. The purpose of this study was to provide accurate data about the inferior limit of dissection.Methods: Forty unpaired cadaver adult lower limbs were used. The anterior tibial artery was identified because it coursed through the interosseous membrane. The perpendicular distance from the lateral joint line and fibula head to this landmark was measured.Results: The anterior tibial artery coursed through the interosseous membrane at 46.3 6 9.0 mm (range 27-62 mm) distal to the lateral tibial plateau and 35.7 6 9.0 mm (range 17-50 mm) distal to the fibula head.Conclusions: Displaced posterolateral tibial plateau fractures require anatomic reduction and stabilization with a buttress plate. This can be achieved by gaining access to the posterolateral tibial cortex. The distal limit of this dissection can be as little as 27 mm distal to the lateral tibial plateau. Dissection in this region should be carried out with caution.

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

IntroductionIntussusception of the appendix is an extremely rare condition that ranges from partial invagination of the appendix to involvement of the entire colon. Endometriosis is an exceptionally rare cause of appendiceal intussusception and only very few cases have been reported in the literature to date.Case presentationA 40 year-old woman presented to clinic with a long history of lower abdominal pain, loose motions and painful, heavy periods. Subsequent colonoscopy revealed submucosal endometriotic nodules in the sigmoid as well as a polyp thought to be arising from the appendix, which had inverted itself. She was referred to a colorectal surgeon because the polyp could not be removed endoscopically despite several attempts. At laparotomy, the appendix had intussuscepted but it was possible to reduce it and therefore a simple appendicectomy was carried out. On histology, there were widespread endometrial deposits within the wall of the appendix and this was thought to be the basis for the intussusception.ConclusionHistological evidence of the lead point is of crucial importance in cases of appendiceal intussusception, in order to exclude an underlying neoplastic process. Consequently, surgical resection is necessary either through an open or a laparoscopic approach. Gastrointestinal endometriosis should be considered as a cause of appendiceal intussusception in post-menarchal women with episodic symptoms and proven disease.