The purpose of this study was to determine whether the reasons for delay to surgery are secondary to health system constraints or patient factors. This study explored factors that contribute to patients' delay to surgery as well as how patients perceive the delay in surgery to have affected their treatment and care.

Semi-structured qualitative interviews were conducted with 30 patients aged 18 to 50 years old who had undergone arthroscopic ACL reconstruction. Qualitative data analysis was performed in accordance with the Straus and Corbin theory to derive codes, categories and themes.

Patient interviews revealed three overarching themes regarding delay to ACL reconstruction surgery: access to care, finances and work, and personal advocacy. Elements of those factors were shown to influence the timing of ACL reconstruction surgery. Less common factors included choice of imaging study (i.e., ultrasound), geography, and family commitments.

Patients' perceptions of delay in access to care was overwhelming due to the wait time for MRI. Several patients also described significant self-advocacy required to navigate the healthcare system, suggesting that some level of medical literacy may be necessary to gain timely access to surgery. Once patients had seen the surgeon, few patients described untimely delay to surgery, suggesting that OR resources are adequate. Recommendations to decrease delays to ACL reconstruction surgery include better access to MRI and broader education of non-surgical healthcare providers to help navigate access to surgery.

Forearm deformity is common in Hereditary Multiple Exostoses, for which multiple surgical treatments exist. Acute ulnar lengthening has been described in the literature, though in small numbers and not independent of adjunctive procedures. We hypothesise that acute ulnar lengthening as a primary procedure is safe and effective in correcting forearm deformity.

Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity, over an eight-year period. Radiographic parameters were assessed and compared preoperatively and postoperatively. Mean follow-up was 27 months. Complications and revisions were noted.

The mean pre-operative ulnar variance, 12.4mm (range 6.1 – 16.5), was significantly reduced post-operatively to a mean 4.6mm (p=<0.00001). A significant acute difference was achieved in carpal slip, (mean change of −2.2mm, p=0.02) but no significant change was seen with regard to radial bowing (p=0.98) or radial articular angle (p=0.74). There were three episodes of recurrence requiring revision. There were no major complications.

Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. Complications were infrequent. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening techniques. Acute ulnar lengthening for forearm deformity associated with HME, has been demonstrated to be a safe, reproducible and effective surgical procedure.

To evaluate effectiveness and safety of acute ulnar lengthening osteotomy in Madelung's deformity associated with Hereditary Multiple Exostoses (HME)

Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity. Defined radiographic parameters were compared pre- and post-operatively using student's t-test; ulnar variance, carpal slip, radial bowing, radial articular angle. All complications were noted.

Mean follow-up was 27 months (range 1.5 – 72months). An increase in ulna length by a mean of 15.4mm (range 4.5 – 29.3mm) was achieved acutely, corresponding to an increase of 9.3% of total ulnar length. Negative ulnar variance was improved from a pre-operative mean of 12.4mm (range 6.1–16.5mm) to a post-operative mean of 4.6mm (range 0–11.25mm) (p=<0.00001). Carpal slip was significantly improved by a mean of 2.2mm (p=0.02). No significant change in radial bowing (p=0.98) or radial articular angle (p=0.74) was observed. Inter-rater reliability was excellent (r=0.96, Pearson Correlation).

Three patients required second procedures for recurrence of deformity at 18 months – 6 years following their primary operation. There were no incidences of compartment syndrome, neurovascular injury nor infection. One ulna fractured intra-operatively requiring a longer plate. One patient had a non union which united on revision surgery.

Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. The procedure is safe, with no compartment syndrome nor neurovascular injury and low complications rate. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening. Acute ulnar lengthening for forearm deformity associated with HME has been demonstrated to be a safe, reproducible and effective surgical procedure.