Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement).

Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair.

A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group.

Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed.

Aim

The rise of multidrug-resistant bacteria and the decreasing efficacy of antibiotic therapy in successfully treating biofilm-associated infections are prompting the exploration of alternative treatment options. This study investigates the efficacy of different bioactive glass (BAG) formulations - alone or combined with vancomycin - to eradicate biofilm. Further, we study the influence of BAG on pH and osmotic pressure as important factors limiting bacterial growth.

Excessive resident duty hours (RDH) are a recognized issue with implications for physician well-being and patient safety. A major component of the RDH concern is on-call duty. While considerable work has been done to reduce resident call workload, there is a paucity of research in optimizing resident call scheduling. Call coverage is scheduled manually rather than demand-based, which generally leads to over-scheduling to prevent a service gap. Machine learning (ML) has been widely applied in other industries to prevent such issues of a supply-demand mismatch. However, the healthcare field has been slow to adopt these innovations. As such, the aim of this study was to use ML models to 1) predict demand on orthopaedic surgery residents at a level I trauma centre and 2) identify variables key to demand prediction.

Daily surgical handover emails over an eight year (2012-2019) period at a level I trauma centre were collected. The following data was used to calculate demand: spine call coverage, date, and number of operating rooms (ORs), traumas, admissions and consults completed. Various ML models (linear, tree-based and neural networks) were trained to predict the workload, with their results compared to the current scheduling approach. Quality of models was determined by using the area under the receiver operator curve (AUC) and accuracy of the predictions. The top ten most important variables were extracted from the most successful model.

During training, the model with the highest AUC and accuracy was the multivariate adaptive regression splines (MARS) model, with an AUC of 0.78±0.03 and accuracy of 71.7%±3.1%. During testing, the model with the highest AUC and accuracy was the neural network model, with an AUC of 0.81 and accuracy of 73.7%. All models were better than the current approach, which had an AUC of 0.50 and accuracy of 50.1%. Key variables used by the neural network model were (descending order): spine call duty, year, weekday/weekend, month, and day of the week.

This was the first study attempting to use ML to predict the service demand on orthopaedic surgery residents at a major level I trauma centre. Multiple ML models were shown to be more appropriate and accurate at predicting the demand on surgical residents as compared to the current scheduling approach. Future work should look to incorporate predictive models with optimization strategies to match scheduling with demand in order to improve resident well being and patient care.

Aim

Several local antibiotic-eluting drug delivery systems have been developed to treat bacterial bone infections. However, available systems have significant shortcomings, including suboptimal drug-release profiles with a burst followed by subtherapeutic release, which may lead to treatment failure and selection for drug resistance.

Here, we present a novel injectable, biocompatible, in situ-forming depot, termed CarboCells, which can be fine-tuned for the desired antibiotic-release profile. The CarboCell technology has flexible injection properties that allow surgeons to accurately place antibiotic-eluting depots within and surrounding infectious sites in soft tissue and bones. The CarboCell technology is furthermore compatible with clinical image-guided injection technologies.

These studies aimed to determine the therapeutic potential of CarboCell formulations for treatment of implant-associated osteomyelitis by mono- and dual antimicrobial therapy.

Aim

There are no definitive criteria for the definition of osteomyelitis in the hand and wrist and published case series are small. It remains a relatively uncommon, but difficult to treat problem. We present a series of 30 cases from 2016 to 2021 from a tertiary referral centre. We propose that the principles of thorough surgical debridement, dead space management, skeletal stabilisation and culture driven antibiotic therapy are the key to management of osteomyelitis in the hand and wrist. In addition, we show how these basic principles can be used for both functional and aesthetic impact for the wrist and digits with illustrated cases.

High energy pelvic injury poses a challenging setting for the treating surgeon. Often multiple injuries are associated, which makes the measurement of short- and long-term functional outcomes a difficult task. The purpose of this study was to determine the incidence of pelvic dysfunction and late impacts of high energy pelvic ring fractures on pelvic floor function in women, with respect to urinary, sexual and musculoskeletal function. This was compared to a similar cohort of women with lower limb fractures without pelvis involvement.

The data in our study was prospectively gathered between 2010 and 2013 on 229 adult females who sustained injury between 1998 and 2012. Besides demographic and operative variables, the scores of three validated health assessment tools were tabulated: King's Health Questionnaire (KHQ), Female Sexual Function Index (FSFI) and the Short Musculoskeletal Functional Assessment (SMFA). A multivariate regression analysis was done to compare groups.

The incidence of sexual dysfunction was 80.8% in the pelvis and 59.4% in the lower extremity group. A Wilcoxon rank sum test showed a significant difference in KHQ-score (p<0.01) with the pelvis group being worse. When adjusting for age, follow-up and Injury Severity Score this difference was not significant (p=0.28), as was for FSFI and SMFA score. The mean FSFI scores of both groups met the criteria for female sexual dysfunction (<26). Patients with a Tile C fracture have better FSFI scores (16.98) compared to Tile B fractures (10.12; p=0.02). Logistic regression predicting FSFI larger than 26.5 showed that older age and pelvic fractures have a higher likelihood having a form of sexual dysfunction.

Sexual dysfunction after lower extremity trauma is found in patients regardless of pelvic ring involvement. Urinary function is more impaired after pelvic injuries, but more data is needed to confirm this. Older age and pelvic fracture are predictors for sexual dysfunction in women. This study is important as it could help counsel patients on the likelihood of sexual dysfunction, something that is probably under-reported and recognized during our patient follow up.

Gram-negative prosthetic joint infections (GN-PJI) present unique challenges in management due to their distinct pathogenesis of biofilm formation on implant surfaces. To date, there are no animal models that can fully recapitulate how a biofilm is challenged in vivo in the setting of GN-PJI. The purpose of this study is to establish a clinically representative GN-PJI in vivo model that can reliably depict biofilm formation on titanium implant surface. We hypothesized that the biofilm formation on the implant surface would affect the ability of the implant to be osseointegrated.

The model was developed using a 3D-printed, medical-grade titanium (Ti-6Al-4V), monoblock, cementless hemiarthroplasty hip implant. This implant was used to replace the femoral head of a Sprague-Dawley rat using a posterior surgical approach. To induce PJI, two bioluminescent Pseudomonas aeruginosa (PA) strains were utilized: a reference strain (PA14-lux) and a mutant strain that is defective in biofilm formation (DflgK-lux). PJI development and biofilm formation was quantitatively assessed in vivo using the in vivo imaging system (IVIS), and in vitro using the viable colony count of the bacterial load on implant surface. Magnetic Resonance Imaging (MRI) was acquired to assess the involvement of periprosthetic tissue in vivo, and the field emission scanning electron microscopy (FE-SEM) of the explanted implants was used to visualize the biofilm formation at the bone-implant interface. The implant stability, as an outcome, was directly assessed by quantifying the osseointegration using microCT scans of the extracted femurs with retained implants in vitro, and indirectly assessed by identifying the gait pattern changes using DigiGaitTM system in vivo.

A localized prosthetic infection was reliably established within the hip joint and was followed by IVIS in real-time. There was a quantitative and qualitative difference in the bacterial load and biofilm formation between PA14 and DflgK. This difference in the ability to persist in the model between the two strains was reflected on the gait pattern and implant osseointegration.

We developed a novel uncemented hip hemiarthroplasty GN-PJI rat model. This model is clinically representative since animals can bear weight on the implant. PJI was detected by various modalities. In addition, biofilm formation correlated with implant function and stability. In conclusion, the proposed in vivo GN-PJI model will allow for more reliable testing of novel biofilm-targeting therapetics

The purpose of this study was to assess the knowledge acquired from completing online case-based e-learning modules. A secondary objective was to identify how students use these independent resources and gauge their level of support for this novel instructional strategy.

Fourth year medical students were randomized to either a module or control group. Both groups received the standard musculoskeletal medical school curriculum, while the students in the module group were also given access to case-based online modules created to illustrate and teach important orthopaedic concepts related to unique clinical presentations. The first module depicted an athlete with an acute knee dislocation while the second module portrayed a patient with hip pain secondary to femoral acetabular impingement (FAI). All participating students completed a knowledge quiz designed to evaluate the material presented in the module topics, as well as general musculoskeletal concepts taught in the standard curriculum. Following the quiz, the students were invited to share their thoughts on the learning process in a focus- group setting, as well as an individual survey. Demographic data was also collected to gauge student's exposure to and interest in orthopaedics, emergency medicine, anatomy and any prior relevant experience outside of medicine.

Twenty-five fourth year medical students participated in the study with 12 randomized to the module group and 13 to the control group. The regression revealed students in the module group did on average 18.5 and 31.4 percentage points better on the knee and hip quizzes respectively, compared to the control group, which were both significant with a p-value < 0.01. Additionally, students who had completed an orthopaedics elective did 20 percentage points better than those who had not, while there was no significant improvement in students who had just completed their core orthopaedics rotation. The feedback collected from the survey and small group discussion was positive with students wishing more modules were available prior to musculoskeletal clinical skills sessions and their orthopaedics rotations.

Medical students given access to online case-based e-learning modules enjoyed the innovative teaching strategy and performed significantly better on knowledge quizzes than their classmates who only received the standard musculoskeletal curriculum.

The New Zealand Joint Registry (NZJR) was established in 1999. However, ethnicity data was not recorded by prioritisation in line with Ministry of Health (MoH) recommendations. Recently, cross-referencing with MoH updated ethnicity data for all 326,150 entries in the NZJR database. The objective of this national level, population study was to identify any ethnic disparities in access and outcome for Māori for primary total hip (THA) and knee arthroplasty (TKA) for Osteoarthritis.

The utilisation rate for THA and TKAs were calculated for the Māori and NZ European population from all data in the NZJR and Census data in 2001, 2006, 2013 and 2018. Utilisation rate was reported separately for four age groups (<55, 55-64, 65-74, >75) over four time periods (1999-2004, 2005-2009, 2010-2014, 2015-2020). Revision rate, 6 months and 5-year Oxford scores were adjusted for age, sex and BMI, then compared between groups.

In every age group and at all but one time point, significant under-utilisation of TKA was observed in Māori. For THAs, Māori had similar utilisation rates in the <55 and 55-64 age groups, but significantly lower utilisation rates in all other age groups.

When adjusted for age, sex and BMI, no significant differences in revision rates were observed between Māori and NZ Europeans for THAs (HR 0.939, P 0.417) or TKAs (HR 1.129, P 0.149). Adjusted 6 months and 5-year Oxford scores were significantly higher in NZ Europeans, however, the maximum difference was less than 3 points and is unlikely to be clinically significant.

Despite the same risk of being diagnosed with osteoarthritis, Māori are less likely to undergo THA and TKA. There are no clinically significant differences in outcomes post arthroplasty between Māori and NZ Europeans. Further research is required to investigate causes for lower utilisation in Māori.

Aim

At our tertiary orthopaedic centre, mycobacterial cultures are routinely performed on bone and joint samples sent for bacterial culture. We have previously described the prevalence Mycobacterium tuberculosis Complex (MTBC) in these samples. Here, we describe the prevalence of non-tuberculous mycobacteria (NTM). We calculate the number needed to test to identify one previously undiagnosed mycobacterial bone or joint infection.

3D printing and Bioprinting technologies are becoming increasingly popular in surgery to provide a solution for the regeneration of healthy tissues. The aim of our project is the regeneration of articular cartilage via bioprinting means, to manage isolated chondral defects.

Chrondrogenic hydrogel (chondrogel: GelMa + TGF-b3 and BMP6) was prepared and sterilised in our lab following our standard protocols. Human adipose-derived mesenchymal stem cells were harvested from the infrapatellar fat pad of patients undergoing total knee joint replacements and incorporated in the hydrogel according to our published protocols. The chondrogenic properties of the chondrogel have been tested (histology, immunohistochemistry, PCR, immunofluorescence, gene analysis and 2^nd harmonic generation microscopy) in vitro and in an ex-vivo model of human articular defect and compared with standard culture systems where the growth factors are added to the media at repeated intervals.

The in-vitro analysis showed that the formation of hyaline cartilage pellet was comparable between the two strategies, with a similar metabolic activity of the cells. These results have been confirmed in the ex-vivo model: hyaline-like cartilage was observed within the chondral defect in both the chondrogel group and the control group after 28 days in culture.

The use of bioprinting techniques in vivo requires the ability of stem cells to access growth factors directly in the environment they are in, as opposed to in vitro techniques where these factors are provided externally at recurrent intervals. This study showed the successful strategy of incorporating chondrogenic growth factors for the formation of hyaline-like cartilage in vitro and in an ex-vivo model of chondral loss.

The incorporation of chondrogenic growth factors in a hydrogel is a possible strategy for articular cartilage regeneration.

In Asia, traditional bands are placed around limbs of children to ward off evil spirits and ensure good health. This practice may lead to the Rubber Band Syndrome (RBS) a rare paediatric condition described mainly in Asia which results from a forgotten thread or elastic band applied to the limb of a child. Because pressure necrosis beneath the band is slow, rapid healing of tissues over the band can obscure its presence. This makes the condition difficult to diagnose and distinguish from other infective conditions. This study presents the first case of RBS reported in South Africa.

Case: The patient aged 18 months presented with a swollen hand, circumferential scar and discharging sinus on the wrist. A radiograph was negative. In theatre the volar wound was explored. Debridement revealed a yellow rubber band deep to the wrist flexors and neurovascular bundles but superficial to the extensor retinaculum. Complete removal of the rubber band and antibiotics was followed by rehabilitation with Occupational Therapy. At a 3 month follow up, there was no evidence of infection, sensation was normal and motor function of the hand restored.

In this case, the structures through which the band had already passed were intact and overlay the band. It would appear that as the band slowly eroded the underlying structures it was followed by healing along the tract until the band exited deep to these structures. The band may come to rest on bone causing osteomyelitis if allowed to progress.

A high index of suspicion of RBS is needed in children presenting with a circumferential scar and a non-healing wound, especially on the wrist or ankle. Careful debridement and complete removal of the band are essential to resolve symptoms and restore function

Aims

The microbiological detection of microorganisms plays a crucial role in the diagnosis as well as in the targeted systemic and local antibiotic therapy of periprosthetic infections (PJI). Despite extensive efforts to improve the sensitivity of current culture methods, the rate of culture-negative infections is approximately 10–20% of all PJI. This study investigates an preanalytical algorithm (culture collection and direct processing in the OR) to potentially increasing culture yield in patients with PJI.

Aim

The aim of this study was to investigate the clinical relevance of an isolated positive sonication fluid culture (SFC) in patients who underwent revision surgery of a prosthetic joint. We hypothesized that cases with a positive SFC have a higher rate of infection and prosthesis failure during follow-up compared to controls with a negative SFC.

Children with osteogenesis imperfecta (OI) frequently present with coxa vara (CV). Skeletal fragility, severe deformity and limited fixation options make this a challenging condition to correct surgically. Our study aimed to determine the efficacy of the Fassier technique to correct CV and determine the complication rate.

Retrospective, descriptive case series from a tertiary hospital. We retrospectively reviewed records of a cohort of eight children (four females, 12 hips) with OI (6/8 Sillence type III, 2/8 type IV) who had surgical treatment with Fassier technique for CV between 2014 and 2020.

Inclusion Criteria: All patients with CV secondary to OI treated surgically with Fassier technique.

Exclusion Criteria: Patients older than 18 years; Patients with CV treated non-operatively or by surgical technique different to Fassier technique.

Data relating to the following parameters was collected and analyzed: demographic data, pre- and postoperative neck shaft angle (NSA), complications and NSA at final follow-up.

The mean age at operation was 5.8 years (range 2–10). The mean NSA was corrected from 96.8° preoperatively to 137º postoperatively. At a mean follow-up of 38.6 months, the mean NSA was maintained at 133°, and 83% (10/12) of hips had an NSA that remained greater than 120°. There was a 42% (5/12) complication rate: three Fassier–Duval rods failed to expand after distal epiphyseal fixation was lost during growth; one Rush rod migrated through the lateral proximal femur cortex with recurrent coxa vara; and one Rush rod migrated proximally and required rod revision.

The Fassier technique effectively corrected CV in children with moderate and progressively deforming OI. The deformity correction was maintained in the short term. The complication rate was high, but mainly related to the failed expansion of the Fassier–Duval rods.

Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired.

We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility.

This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile.

Distal radius fractures are common in South Africa. Accurate, decisive radiographic parameter interpretation is key in appropriate management. Digital radiographic facilities are rare in the public setting and goniometer usage is known to be low, thus, visual estimates are the primary form of radiographic assessment. Previous research associated orthopaedic experience with accuracy of distal radius fracture parameter estimation but, oftentimes, doctors treating orthopaedic patients are not experienced in orthopaedics.

A cross-sectional questionnaire including four distal radius fracture radiographs administered to 149 orthopaedic doctors at three Johannesburg teaching hospitals. Participants grouped into ranks of: consultants (n=36), registrars (n=41), medical officers (n=20) and interns (n=52). Participants visually estimated values of distal radius fracture parameters, stated whether they would accept the position of the fractures and stated their percentage of routine usage of goniometers in real practice.

The registrar group was most accurate in visually estimating radial height, whilst the interns were least accurate (p=0.0237). The consultant, registrar and medical officer groups were equally accurate in estimating radial inclination whilst the intern group was the least accurate (p<0.0001). The consultant and registrar group were equally accurate at estimating volar tilt, whilst the medical officer and intern groups were least accurate (p<0.0001). The Gwet's AC agreement was 0.1612 (p=0.047) for acceptance of position of the first radiograph, 0.8768 (p<0.0001) for the second, 0.8884 (p<0.0001) for the third and 0.8064 (p<0.0001) for the fourth. All groups showed no difference in goniometer usage, using them largely 0–25% of practice (p=0.1937).

The study found that accuracy in visual estimations of distal radius fracture parameters was linked to orthopaedic experience but not linked to routine practice goniometer usage, which was minimal across all groups. Inter-rater agreement on acceptability of fracture position is potentially dependent on severity of deviation from acceptable parameters.

To analyse the causes and factors associated with mortality in patients admitted to ASCI unit in a low- or middle-income country. The study was performed at a Tertiary Hospital at Groote Schuur Hospital, Cape Town South Africa

Data between 1996 –2022 were retrospectively collected from hospital records of patients admitted to the ASCI Unit. There was approximately 3223 admissions for the study period. 682 patients were confirmed dead 87% were male and 64% were unemployed. The mean age was 46 years (ranging from 14 – 87 years).

A 1/3 of injuries were caused by a MVA, a ¼ by a fall (low energy and from a height), and 1/5 by a gunshot wound. Average length of stay was 47 days (SD = 52 days), ranging from as short as 1 day to 512 days for one patient. Majority (65%) were admitted for more than a week but less than 2 months 32% were ventilated, and 17% with a CPAP facemask. 10% of patients had a pre-existing ulcer prior to admission. 65% of patients had surgery via the posterior approach, 33% via the anterior approach. On average patients died within 5 years of being admitted to hospital, ranging from dying in the same year as the injury to 20 years later. 73% of the deaths were classified as natural deaths and 20% as unnatural.

There is a high mortality in patients with acute spinal cord injury, causes are multifactorial, and in depth critical analyses is required to improve clinical outcomes and rationalise resource allocation.

The use of cannabis is increasingly medically relevant as it is legalized and gains acceptance more broadly. However, the effects of marijuana use on postoperative outcomes following orthopedic surgery have not been well-characterized. This study seeks to illuminate the relationship between marijuana use and the incidence postoperative complications including: DVT, PE, nonunion, and infection following common orthopedic procedures.

This study was conducted using a national orthopaedic claims insurance database. We identified all patients undergoing knee arthroscopy, shoulder arthroscopy, operatively managed long bone fractures (humerus, femur, tibia and/or fibula, and radius and/or ulna), and single-level lumbar fusion. The proportion of patients within each surgery cohort who had a diagnostic code for marijuana dependence was assessed. The rates of DVT, PE, and infection within 90 days were assessed for all patients. The rate of nonunion was assessed for the long bone fracture and lumbar fusion cohorts. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities.

We identified 1,113,944 knee arthroscopy, 747,938 shoulder arthroscopy, 88,891 lumbar fusion, and 37,163 long bone fracture patients. Out of the 1,987,936 patients, 24,404 patients had a diagnostic code for marijuana dependence. Within all four surgical subgroups, the marijuana dependence cohort experienced increased rates of infection, PE, and DVT, as well as increased rates of nonunion in the lumbar fusion and long bone fracture populations. In the multivariate analyses controlling for a variety of patient risk factors including tobacco use, marijuana dependence was identified as an independent risk factor for infection within all four surgical subgroups (Knee: OR 1.85, p < 0.001; Shoulder: OR 1.65, p < 0.001; Spine: OR 1.45, p < 0.001; Long bone: OR 1.28, p < 0.001), and for nonunion in the lumbar fusion (OR 1.38, p < 0.001) and long bone fracture (OR 1.31, p < 0.001) subgroups.

Our data suggests that marijuana dependence may be associated with increased rates of infection and nonunion following a variety of orthopaedic procedures. During preoperative evaluation, surgeons may consider marijuana use as a potential risk factor for postoperative complications, especially within the context of marijuana legalization. Future research into this relationship is necessary.

In 2007, the National Hip Fracture Database (NHFD) was conceived in the United Kingdom (UK) as a national audit aiming to improve hip fracture care across the country. It now represents the world's largest hip fracture registry. The purpose of the NHFD is to evaluate aspects of best practice for hip fracture care, at an institutional level, that reflect the evidence-based clinical guidelines and quality standards developed by the National Institute for Health and Care Excellence. No national program currently exists, equivalent to the NHFD, in Canada despite evidence suggesting that national audit programs can significantly improve patient outcomes. The purpose of this study was to evaluate aspects of best practice for hip fractures at our Canadian academic tertiary referral center using the Key Performance Indicators (KPI) and benchmarks used by the NHFD. In doing so, we aimed to compare our performance to other hospitals contributing to the NHFD database.

A retrospective cohort study was conducted on consecutive patients who presented to our Canadian center for surgical management of a hip fracture between August 2019 to September 2020. Fracture types included intertrochanteric, subtrochanteric, and femoral neck fractures treated with either surgical fixation or arthroplasty. Cases were identified from the affiliate institute's Operatively Repaired Fractures Database (ORFD). The ORFD prospectively collects patient-level data extracted from electronic medical records, operating room information systems, and from patients’ discharge summaries. All applicable data from our database were compared to the established KPI and benchmarks published by the NHFD that apply to the Canadian healthcare system.

Six hundred and seven patients’ data (64.5% female) were extracted from the ORFD, mean age 80.4 ± 13.3 years. The NHFD contains data from 63,284 patients across the entire UK. The affiliate institute performed inferiorly compared to the NHFD for two KPIs: prompt surgery (surgery by the day following presentation with hip fracture, 52.8% vs. 69%) and prompt mobilization after surgery (mobilized out of bed by the day after operation, 43.0% vs. 81.0%). However, more patients at the affiliate institute were not delirious when tested postoperatively (89.6% vs. 68.4%). There was no significant difference in the average length of stay (12.23 days versus 13.5 days) or in 30-day mortality rate (8.4% versus 8.3%).

More than half of all KPI's and benchmarks for patients receiving a hip fracture surgery at our tertiary referral center in Canada ranked significantly lower than patients receiving a hip fracture surgery in the UK. These findings indicate that perhaps a national audit program should be implemented in Canada to improve aspects of hip fracture care, at an institutional level. Following evidence-based clinical guidelines and using standardized benchmarks would encourage change and foster improvement across Canadian centres when necessary.