Aims

The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

Aims. National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD. Methods. We compared 17 hip fracture registries covering 20 countries (Argentina; Australia and New Zealand; China; Denmark; England, Wales, and Northern Ireland; Germany; Holland; Ireland; Japan; Mexico; Norway; Pakistan; the Philippines; Scotland; South Korea; Spain; and Sweden), setting each of these against the 20 core and 12 optional fields of the MCD. Results. The highest MCD adherence was demonstrated by the most recently established registries. The first-generation registries in Scandinavia collect data for 60% of MCD fields, second-generation registries (UK, other European, and Australia and New Zealand) collect for 75%, and third-generation registries collect data for 85% of MCD fields. Five of the 20 core fields were collected by all 17 registries (age; sex; surgery date/time of operation; surgery type; and death during acute admission). Two fields were collected by most (16/17; 94%) registries (date/time of presentation and American Society of Anesthesiologists grade), and five more by the majority (15/17; 88%) registries (type, side, and pathological nature of fracture; anaesthetic modality; and discharge destination). Three core fields were each collected by only 11/17 (65%) registries: prefracture mobility/activities of daily living; cognition on admission; and bone protection medication prescription. Conclusion. There is moderate but improving compatibility between existing registries and the FFN MCD, and its introduction in 2022 was associated with an improved level of adherence among the most recently established programmes. Greater interoperability could be facilitated by improving consistency of data collection relating to prefracture function, cognition, bone protection, and follow-up duration, and this could improve international collaborative benchmarking, research, and quality improvement. Cite this article: Bone Joint J 2023;105-B(9):1013–1019

Background. National hip fracture programmes are becoming widespread, but this practice is nascent and varied. The Scottish Hip Fracture Audit (SHFA) was an early adopter of this strategy and is credited with substantial systemic improvements in quality and outcomes. Objectives. To provide evidence and incentive to clinicians and administrators to adopt successful improvement strategies, and to facilitate data-driven change hip fracture care. Study Design and Methods. We reviewed the practice of seven national hip fracture improvement programmes in: Sweden, Denmark, Norway, Australia, New Zealand, UK, Scotland, and Ireland. We report our experience from the SHFA and describe: the results of our programme; challenges and learning points encountered, and successful strategies for implementing change. Results. There is variance in approach to data collection and reporting, for example: standalone programmes versus combined trauma and arthroplasty registries; annual trend reporting versus ‘snapshot’ or real-time information; population-level versus patient-level data, and the emphasis placed on service-level characteristics. The governance model also varies – some act as a passive data registry whereas others act as active agents of change and regulation. There is consensus on the key performance makers: prompt admission; early surgery and mobilisation, and a multidisciplinary approach. There have been significant challenges encountered by the SHFA with respect to funding, logistical, and political issues. Analysis of the effects of our programme have demonstrated its clinical efficacy, and has identified successful strategies for improvement. We describe this experience. Conclusions. The establishment of national audit programmes has resulted in significant improvements in quality, efficiency, and outcomes. This study of major national programmes provides evidence, incentive, and instruction to clinicians and administrators who seek to improve healthcare systems

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies. A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance. 13638 records were included (72% female). 9867 received a SHS (72%). No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's. There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS. Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted

Collection of new data for the Scottish hip fracture audit stopped in December 2008. The proposed standard of operating on 98% of all hip fractures within 24 hours of admission, subject to medical fitness and during safe operating hours should now be maintained. Methods. We prospectively collected data from 102 consecutive hip fracture patients documenting the patient's journey from admission to discharge from the orthopaedic ward to look at whether the standard had been maintained. Results. 50% of patients get to theatre 24hrs or earlier with 60% catheterised perioperatively.50% of patients were moved from the acute orthopaedic facility at a week with less than 20% of these getting back to their usual place of residence. 25% were still on the acute ward at two weeks and 3% died in the immediate post operative period. However, the number of co-morbidities did not seem to correlate with time to discharge. The majority of patients transferred to onward care moved to the geriatric rehabilitation ward within the hospital. Prioritisation of hip fracture patients on the trauma list needs to be continued along with improvements in the availability of rehabilitation beds. Pre-operative medical work up for patients with reversible illness and post-operative geriatric care will improve the outcomes for these frail patients

Background The clinical standards board in Scotland has recognized hip fractures as the most common injury in older people. Hip fracture care is now emerging as a case study for clinical governance in Scotland. Aims/Methods The results of a prospective audit of 1177 hip fractures admitted to Wishaw General Hospital over a 36 month period are presented. All aspects of care from admission to discharge are analyzed, and patients followed up for 4 months after discharge. Results Pre Fracture The most common age group of patients was 80–90 Yrs (40.9%). 10 % of patients were over 90 Yrs.80.3% were female. There was no significant difference in side involved (L 53.3%: R 46.7%).60.1% patients were admitted from own home.71 patients (6%) originated from other wards within the hospital.39.6% patients were found to be living alone. Only 25.9% patients walked alone out of doors before fracture, while 39.1% walked alone indoors but not out of doors.43.8% could walk with out aids. Surgery 52.9% underwent osteosynthesis with screws and plate.34.2% had hemiarthroplasty.3.4% had total hip replacement. 4.1% was treated conservatively.48.3% had general anaesthetic and 47.4% regional anaesthetic.93 % received thromboembolic prophylaxis, and 96% antibiotic prophylaxis. The post operative wound infection rate was 3.2%. 4.9% required a second surgical procedure within 4 months. These included 14 patients who had dislocated prosthesis reduction, 14 conversions to total hip replacement, 9 conversions of osteosynthesis to hemiarthroplasty and 5 refixations. Post Fracture (4 Months) 41.9 % returned to their own home, while 14.7 went into nursing homes.11% were able to walk out of doors alone, and 28% could walk in doors alone. Only 7% could mobilize without and aids, 19.2% used one aid and 30.2% required a walking frame.41.6 % had no hip pain, 18.2 % complained of slight or intermittent discomfort.

Conclusions Older patients (80 Yrs +) are at significant risk of sustaining hip fractures. The risks are greater in patients living alone and in females. Patients with significant co morbidity may have to be treated conservatively. There is a considerable risk of requiring a second surgery. Only about 69 % of patients living in their own homes are able to do the same after fracture. Only about 50 % of previously independent patients were able to regain the same level of mobility.

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies. Cite this article: Bone Joint Res 2022;11(6):342–345

The hip fracture burden on health and social care services in Scotland is anticipated to increase significantly, primarily driven by an ageing population. This study forecasts future hip fracture incidence and the annual number of hip fractures in Scotland until 2029. The monthly number of patients with hip fracture aged ≥ 50 admitted to a Scottish hospital between 01/01/2017 and 31/12/2021 was identified through data collected by the Scottish Hip Fracture Audit. This data was analysed using Exponential Smoothing and Auto Regressive Integrated Moving Average forecast modelling to project future hip fracture incidence and the annual number of hip fractures until 2029. Adjustments for population change were accounted for by integrating population projections published by National Records of Scotland. Between 2017 and 2021 the annual number of hip fractures in Scotland increased from 6675 to 7797, with a respective increase in hip fracture incidence from 313 to 350 per 100,000. By 2029, the averaged projected annual number of hip fractures is 10311, with an incidence rate of 463 per 100,000. The largest percentage increase in hip fracture occurs in the 70-79 age group (57%), with comparable increases in both sexes (30%). Based upon these projections, overall length of stay following hip fracture will increase from 142713 bed days per annum in 2021, to 203412 by 2029, incurring an additional cost of over £25 million. Forecast modelling demonstrates that the annual number of hip fractures in Scotland will rise substantially by 2029, with considerable implications for health and social care services

COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture. This nationwide cohort study included all patients aged >50 years with a hip fracture between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to population-level records of COVID-19 vaccination and testing. There were 13,345 patients with a median age of 82.0 years (IQR 74.0–88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34–0.48, p<0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12–3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk (OR 0.93, CI 0.53–1.60, p = 0.783). Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents essential data for future outbreaks

Hip fracture represents a significant challenge, placing increasing pressure on health and social care services in Scotland. This study establishes the ‘historic’ hip fracture burden, namely, the annual number of hip fractures in Scotland, and respective incidence, between 2017 – 2021. Furthermore, the ‘projected’ hip fracture burden and incidence from 2022 – 2029 was estimated, to inform future capacity and funding of health and social care services. The number of individuals with a hip fracture in Scotland between 2017 and 2021 was identified through the Scottish Hip Fracture Audit, enabling the annual number of hip fractures and respective incidence between 2017 – 2021 to be calculated. Projection modelling was performed using Exponential Smoothing and Auto Regressive Integrated Moving Average to estimate the number of hip fractures occurring annually from 2022 – 2029. A combined average projection was employed to provide a more accurate forecast. Accounting for predicted changes within the population demographics of Scotland, the projected hip fracture incidence up to 2029 was calculated. Between 2017 and 2021 the annual number of hip fractures in Scotland increased from 6675 to 7797 (15%), with an increase in incidence from 313 to 350 per 100,000 (11%) of the at-risk population. Hip fracture was observed to increase across all groups, notably males, and the 70–79 and 80–89 age cohorts. By 2029, the combined average projection estimated the annual number of hip fractures at 10311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. The largest percentage increase in hip fracture by 2029 occurs in the 70–79 and 80–89 age cohorts (57% and 53% respectively). Based upon these projections, overall length of hospital stay following hip fracture will increase by 60699 days per annum by 2029, incurring an additional cost of at least £25 million. Projection modelling demonstrates the annual number of hip fractures in Scotland will increase substantially by 2029, with significant implications for health and social care services. This increase in hip fracture burden and incidence is influenced strongly by changing population demographics, primarily an ageing population

Troponin I is a widespread used blood test to confirm myocardial damage, usually attributable to myocardial infarction. Troponin tests require to be taken 12 hours after the initial event, and thus may be a potential cause for delay. SIGN and Hip Fracture Audit guidelines recommend 98% of patients obtaining surgery within 24hrs of admission. A population of 347 neck of femur patients presenting to Glasgow Royal Infirmary were assessed over a one year period. 44 (13%) Patients were identified as having a pre-operative Troponin I test. Retrospective case note review of this patient cohort who had pre operative troponin testing was undertaken to identify timing of TnI testing, admission, surgery and medical comorbidies. Time to theatre was compared with the 24hr guideline. From the cohort, 32 Patients had case notes which were located, of which 4 had no filed notes from the admission giving a 28 patient sample population. 18 (64%) had a Troponin of ‘negative’ value (<0.04 μg/l) of which the mean delay to theatre from admission was 46.4 hrs (median 44.5hrs). All 18 breached the 24hr target, 5 were delayed >48hrs. Of the 10 ‘postive’ patients, mean TnI was 0.4 and time to theatre was 85hrs (median 69hrs) with one excluded as treated conservatively. Only one patient was treated within the 24hr target (3.7% of sample group treated operatively) p=<0.001. Scottish Hip Fracture Audit shows GRI to have an overall 98.6% compliance with the 24hr target. The data presented shows significant (near complete) failure to meet the 24hr target in patients tested preoperatively for Troponin I. Almost three-quarters of these patients have normal TnI, but delay may be attributable to additional comorbidities

Hip fracture care is complex multi-disciplinary. We hypothesise that quality of care is affected by variance in resources between ‘in-hours’ (Monday-Friday, 0800–1700) and ‘out-of-hours’ services. This prospective multicentre national cohort study assessed quality of care by evaluating adherence to the evidence-based Scottish Standards of Care for Hip Fracture Patients. Data was collected by the Scottish Hip Fracture Audit for 15174 patients admitted to any of 22 Scottish hospitals from January 2014-April 2018. 11197/15174 (73.8%) patients were admitted out-of-hours. They were significantly less likely to meet the following Standards: ED Big-6-Bundle (OR 0.85, p= 0.002); Time in ED <4 hours (OR 0.76, p< 0.001); avoidance of repeated fasting (OR 0.80, p< 0.001), and avoidance of prolonged fluid fasting (OR 0.83, p< 0.001). Out-of-hours admissions were more likely to receive: geriatric assessment <3 days (OR 1.16, p< 0.001); OT input <3 days (OR 1.10, p= 0.013), and PT input <2 days (OR 1.44, p< 0.001). There were no significant differences for: Time to Theatre <36 hours; Inpatient Care Bundle <24 hours, and Post-op Day 1 Mobilisation. Quality of hip fracture care is affected by time of admission. ED care is poorer out-of-hours, which may reflect limited resources, and out-of-hours admissions are more likely to be excessive fasted excessively. Weekday in-hours admissions are less likely to receive geriatric and allied health professional input in the days following admission, which may reflect the reduced weekend services. Examination of out-of-hours service organisation is required for the pursuit of consistent, equitable care for hip fracture patients

Aims

The Peri-Implant and PeriProsthetic Survival AnalysiS (PIPPAS) study aimed to investigate the risk factors for one-year mortality of femoral peri-implant fractures (FPIFs).

Aims

Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

Introduction: We investigated the incidence, risk factors and outcome of acute renal dysfunction (ARD) in patients with a fractured neck of femur. Methods: 170 consecutive patients were prospectively included in the Scottish hip fracture audit database and retrospectively analysed. Historically, lack of consensus definition hindered accurate reporting of ARD. We defined ARD using the ‘RIFLE’ criteria recently described by the Acute Dialysis Quality Initiative (ADQI) Group. Results: 27 patients (16%) developed ARD. Risk factors were male sex, vascular disease, hypertension, diabetes, chronic kidney disease and pre-morbid use of nephro-toxic medications (p< 0.01). Inpatient, 30 and 120 day mortality was higher in the ARD group 19%, 22% and 41% respectively, versus 0%, 4% and 13% in the non-ARD group (p< 0.01) Length of hospital stay was significantly longer in the ARD group; 20 days compared to 13 days for patients in the non-ARD group (p< 0.01). Pre and post-operative complications were 12 and 5 times more frequent respectively in the ARD group (p< 0.01). Discussion: Acute renal dysfunction is an important adverse event in this population. Awareness of risk factors and serial measurements of renal function will enable early identification and focused monitoring of these patients

Aims

The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics.

BACKGROUND. Since 1996, the Scottish Hip Fracture Audit (SHFA) group have published reports on the outcomes of patients with hip fractures. In the 2008 report, the group outlined the target standard that “98% of medically fit patients who have sustained a hip fracture should be operated on within 24 hours of ‘safe operating time’ (i.e. between 8 am and 8pm, seven days a week).”. 1. . AIM. We aim to investigate the compliance of our unit to the SHFA target standard. METHODS. We prospectively examined patients who were admitted with hip fractures between 1. st. April to 31. st. July 2011. These included admissions from A&E and inpatients. Patients who did not receive surgical treatment were excluded. Information was collected using the same pro forma as the SHFA group. RESULTS. There were 72 patients with hip fractures in that period. One patient (1.4%) was considered unfit for surgery and therefore excluded. Sixty-five patients were considered fit for surgery on first assessment and 61 (93.8%) had surgery within the target time. There were three patients (4.6%) whose diagnosis was delayed waiting for MRI. The waiting period included a weekend in two patients, when there were no MRI facilities. Only one patient (1.5%) had surgery delayed due to lack of theatre availability. DISCUSSION. Having surgery performed as early as possible is associated with a beneficial impact on morbidity, complications and length of hospital stay. 2–4. , reflected with SIGN guidelines stating “surgery should be performed as soon as the medical condition allows”. 5. and NICE recommending surgery within 48 hours of admission. 6. . CONCLUSION. Although our rate of 93.8% does not meet the target standard, it represents an improvement from the published rate (91.2%) in 2008. It also highlights the areas for improvement in patient care, particularly in getting MRIs swiftly to avoid delays

Hip fracture is a common and serious injury affecting the elderly. Many patients have co-morbidities which may need to be investigated and treated before surgery but, conversely, delay in surgical management of these patients leads to increased morbidity and mortality. The Scottish Hip Fracture Audit (SHFA). 1. conducted in 2007 showed variations between hospitals in postponement rates for medical reasons. The report referred to 11 major clinical abnormalities described by McLaughlin. 2. that were associated with poor postoperative outcomes and should be corrected before surgery. This prospective audit took place in Monklands hospital for a duration of 6 weeks. All patients admitted to the orthopaedic firm from 14. th. Oct 2012 to 26. th. November 2012 with confirmed fracture neck of femur were prospectively included in the audit. A detailed review of the notes took place to identify whether delays were appropriate according to McLaughlin. There were a total of 23 patients admitted during the audit period of which 21 were operated on and 2 patients treated conservatively. The mean age of this cohort was 82.8 (range 55–91) with a male to female ratio of 1:1.3. Sixteen cases (76%) were operated on within 48 hours of admission (11 cases – 52% within 24 hours). Five cases (24%) were delayed by more than 48 hours. Three cases (14%) were delayed due to lack of theatre time. Two patients (9.5%) were delayed due to request of ECHO for ?new murmur. Our practice of managing hip fracture patients is similar to other units in Scotland with a deferral rate of approximately 25%. The patients who have a major clinical abnormality were appropriately investigated and treated before the surgery. Further improvement in management of the theatre time is needed as surgery is delayed for >24 hours in approximately 15% of medically fit hip fracture patients

Aims

The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture.

Aims

This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality.