Primary bone and soft tissue sarcoma treatment includes surgical resection, with or without peri-operative chemoradiotherapy. The aim of surgery is to achieve complete excision, to prevent localised recurrence and achieve cure. For various reasons, excision with adequate margins is not always possible. Our aim is to assess the occurrence of unexpected positive margins following primary excision within a tertiary centre and the impact on patient outcomes. A retrospective analysis of 567 patients discussed at the Royal National Orthopaedic Hospital Multi-disciplinary team (MDT) meeting with positive margins between 1999-2020 was performed. Exclusion criteria included: excisions performed externally and lesions treated with curettage. Information gathering from electronic records highlighted 23 cases with unexpected positive margins following primary excision. All patients pre-operatively expected to achieve complete primary resection. The median age was 60 years (8-92), 10M:13F. Tumour location included lower limb (12), upper limb (six), pelvis (two) and trunk (three); eight bone tumours and 15 soft tissue. The overall recurrence rate was 30.4% (7/23). In those recommended for re-excision (n=16), the recurrence rate was 31.25% (5/16). Of the patients not initially recommended for re-excision (n=7), four proceeded to surveillance alone with 50% recurrence (2/4), both with metastatic disease not surviving to follow-up. A further three patients underwent post-operative radiotherapy alone with no recurrences at follow-up, one patient not surviving for further treatment due to stroke. The mean follow-up for patients was 3.1 years. When positive margins do occur unexpectedly, the impact due to the need for further treatment and ultimately increased risk of recurrence can be significant. Results can be compared to those for unplanned excisions. Therefore, surgeons should be aware of the different circumstances in which positive margins occur to help guide treatment planning and managing patient expectations.

Early surgery is recommended in hip fractures to reduce morbidity and mortality. Surgery is often delayed in patients on novel direct oral anticoagulants (DOACs). The purpose of our study was to investigate the impact of DOACs on patients with hip fractures. A retrospective comparative analysis was performed. A total of 766 patients presented with neck of femur fractures in the study period. Patients under the age of 60, those managed conservatively and those on alternative anticoagulation (including warfarin, clopidogrel and aspirin) were excluded. Forty-seven (6.1%) patients were on DOACs, to which a group of 47 patients was matched for age, gender, fracture type and intervention to minimise confounding. Primary outcome data on time to surgery (TTS), pre-/postoperative haemoglobin, haemoglobin drop, length of stay (LOS) and 30-day mortality were collected, as well as secondary outcome data on blood transfusion and wound complications. The Charlson Comorbidity Index (CCI) was calculated for all patients. The mean Charlson Comorbidity Index was significantly increased in the DOAC group (p<0.0001). The mean time to surgery was 49.5 hours in the DOAC group versus 31.3 hours in the control group (p=0.0002). Haemoglobin drop for DOAC patients was 16.9 g/L and 15.9 g/L for control patients (p=0.6). Similarly, no significant increase in transfusion was required (p=0.74). Six DOAC patients and two control group patients died within 30 days of surgery (p=0.13). Wound complications were seen in five (10.6%) patients on DOAC and two (4.2%) patients in the control group (p=0.02). The results demonstrate statistically significantly higher comorbidities, delay in surgery and higher wound complications in patients on DOAC but no significant difference in haemoglobin drop, blood transfusion and mortality.