Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

III.

In keeping with the universal response to the coronavirus (SARS-CoV-2) pandemic, lockdown measures were introduced in South Africa (SA). The SA government decreed five lockdown alert levels ranging from alert level 5, which entailed drastic measures to contain the spread of the virus to alert level 1, where reintroduction of normal activity was envisioned (Fig. 1). All non-essential activities were suspended. The lockdown included curfews, stay and work from home orders for non-essential workers, and restrictions on gatherings and public transport. Furthermore, the gazetted regulations stipulated an absolute ban on sales of alcohol and tobacco products. In the backdrop of this pandemic, there is the pre-existing quadruple burden of disease that plagues the SA people, aptly referred to as a cocktail of four colliding epidemics: maternal, newborn and child health; HIV/AIDS and tuberculosis (TB); non-communicable diseases; and violence and injury. Injuries are a major contributor to the burden of disease and interpersonal violence accounts for a greater share of the injury burden in SA than most other countries. [1] The homicide rate is among the highest in the world, while road injuries are the third and fourth leading cause of deaths among men and women, respectively. [2] There was a substantial decrease in trauma admissions countrywide and when the police minister, Mr Bheki Cele, was releasing the quarterly crime statistics covering the lockdown period (April -June), he remarked that 'a never-seen-before rosy picture of a peaceful South Africa experiencing a crime holiday' . [3] Over the period which coincided with lockdown, murder was down 35.8%, attempted murder by 39.7%, rape by 40.4% and assault with intent to cause grievous bodily harm by 41%. [3] The number of drunk driving convictions went down by 85.5% and drug-related crime also dropped by 53% nationwide. [3] Patients with preventable major trauma divert critical resources required to manage the COVID-19 crisis. We investigated the impact of lockdown measures on the number of patients with intentional and non-intentional injuries who visited a tertiary urban trauma centre in the Western Cape Province, SA. This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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Aims: To describe the epidemiology and injury severity of patients with extremity gunshot injuries in an area with a high rate of interpersonal violence. Patients and methods: This is a prospective cohort study of patients who presented with an extremity gunshot injury and were recorded as part of a trauma registry at a large tertiary care hospital in Cape Town, South Africa, between June 2015 and April 2016. Patient demographics, injury severity scores, injury patterns and referral pathways were evaluated. Results: Of 1 123 gunshot trauma admissions in ten months, 290 (25.8%) patients (91.5% males, n=269) with a median age of 26 years (IQR 13.0) presented with extremity injuries. Median injury severity score (ISS) was 4.0 (IQR 8.0). Only one-fifth of patients had an ISS of 15 or more (n=50, 17%). Upper extremity injuries were associated with a higher risk of fractures (RR 2.15, p=0.05), higher number of nerve injuries (p=0.01), and a two times higher mean ISS (p=0.01). Admissions between 7pm and 7am with limited staffing at the emergency department were twice as high as the day admissions (n=169, 57.5% versus n=79, 26.9%). Conclusion: There is a high trauma load on the emergency department and orthopaedic service due to extremity gunshot injuries. Although upper extremity gunshot wounds constituted a red flag for higher injury severity, the overall injury severity was low. Inadequate timing and selection of emergency referrals of patients with low ISS are avoidable aggravators of this burden and should be targeted to increase efficiencies in the care of these patients.

Background. Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. Objective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. Methods. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. Results. A total of 111 patients with an average age of 28 years (range 13 -74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 -7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. Conclusion. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives.

Background: Human immunodeficiency virus (HIV) reduces bone mineral density, mineralisation and turnover, and may impair fracture healing.Setting: This prospective cohort study in South Africa investigated whether HIV infection was associated with impaired fracture healing following trauma.Methods: All adults with acute tibia and femur fractures who underwent intermedullary nailing (IM) for fracture fixation between September 2017 and December 2018, at two tertiary hospitals, were followed for a minimum of 12 months post-operatively. The primary outcome was delayed bone union at 6 months (defined by the radiological union scoring system for the tibia [RUST] score <9), and the secondary outcome was non-union (defined as RUST A C C E P T E Dscore <9) at 9 months. Multivariable logistic regression models were constructed to investigate associations between HIV status and impaired fracture healing.Results: In total, 358 participants, who underwent 395 IM nailings, were enrolled in the study and followed up for 12 months. Seventy-one participants (71/358, 19•8%) were HIV positive (83 IM nailings [83/395], 21.0%). HIV was not associated with delayed fracture healing after IM nailing of the tibia or femur (multivariable odds ratio [OR]: 1•06; 95% confidence interval [CI]: 0•50-2•22). Participants with HIV had a statistically significant lower odds of non-union compared to HIV-negative participants (multivariable OR: 0•17; 95% CI: 0•01-0•92). Conclusions:Fractures sustained in HIV-positive individuals can undergo surgical fixation as effectively as those in individuals who are HIV negative, with no increased risk of delayed union or non-union. Funding: This study was funded by a Wellcome Trust Research and Training PhD Fellowship and support from the AOUK foundation.