Introduction: Fractures of the neck of femur has a considaerable impact on the NHS and due to the elderly group of population it involves morbidity can be very costly. We assesed the outcome of trauma patients with these fractures after providing orthogeriatric care in our hospital. Aim: 179 patients had been studied who had been managed in our hospital over a period of 18 months with hemiarthroplasty for displaced intracapsular fracture of the neck of femur. 104 patients had routine orthopaedic care and 75 patients had regular orthogeriatric care. All the complication were noted, analysed and compared with the national averages. Methodology: This was a retrospective study-clincal notes of all patients who had hemiarthroplasty during the 18 month period were reviewed and a performa was completed. Result: Total sample size was 179 patients(104 before and 75 after the introduction of orthogeriatric service) who had hemiartroplasty for the displaced intracapsular fracture of the neck of femur. The median length of stay being 16.5 days before and 20 days after. The medical complications before and after the introduction of this service were-Cardiac complication 4% before and 1% after, Chest infection 2% before and 1% after, DVT 2% before and 1% after. The Overall complication rate has been reduced from 41% to 18% and the one year mortality reduced from 16.34% to 12 with the introduction of orthogeriatric service. Conclusion: We believe that the weekly ward round and a continued supervision by the orthogeriatric team is one of the factors in improving the outcome of geriatric trauma patients in terms of reduced morbidity and mortality

Introduction. In the orthogeriatric model of care, orthopaedic surgeons, geriatricians, anesthesiologists, physiotherapists and the nursing staff work together with the aim to optimize the outcomes of vulnerable older patients undergoing orthopaedic surgery. It is recommended that the orthogeriatric care of hip fracture patients should be based on systematic treatment guidelines. We describe here how operative and perioperative management of hip fracture patients changed between the first and the second year after initiation of orthogeriatric collaboration. Method. Data on all patients aged 65 years or over and experiencing a hip fracture between September 1st 2007 and August 31st 2009 were prospectively collected in a Finnish hospital district with a total of 200,000 inhabitants. The patients were evaluated 4–6 months postoperatively at the geriatric outpatient clinic. Starting from the second year, geriatrician's rounds 2–3 times a week at the orthopaedic ward were provided. In addition, a systematic treatment protocol agreed by orthopaedic surgeons, geriatricians and anesthesiologists was introduced to the hospital staff responsible for the care of hip fracture patients. Results. Data were available on 177 patients in the first and 232 patients in the second year (87 % and 95 % of eligible patients, respectively). There were no significant differences in the patient characteristics in regard with age, sex distribution, prefracture mobility level, living arrangements, number of medication used, body mass index, anesthesiological risk score or the type of the fracture between the two years. Compared to the first year, the patients were more likely to be operated by a consultant orthopaedic surgeon (74 % vs. 49 %, p<0.001) and to undergo hemiarthroplasty (64 % vs. 53 %, p=0.013) during the second year. Urinary catheters were also removed before discharge from the orthopaedic ward more frequently (28 % vs. 14 %, p=0.001). There was a trend towards shorter delay to operation (<24 hours in 40 % vs. 32 %, p=0.140) and more frequent use of blood transfusions (39 % vs. 32 %, p=0.128). There was no difference in the mean length of stay at the orthopaedic ward between the two years (6 days in the first vs. 7 days in the second year, p=0.081). The 4-month mortality was 20 % in the first and 17 % in the second year (p=0.436). Conclusions. The treatment practices showed changes towards guideline recommendations after initiation of orthogeriatric collaboration in the care of hip fracture patients without increasing the length of stay at the orthopaedic ward. Further follow-up is required to show how these improvements translate into longer-term outcomes and mortality

Objectives: To determine the effect of an Orthogeriatric team (OGT) upon patient management pre-operatively after its incorporation into a regional trauma centre of a district general hospital in the UK. Design: Prospective audit covering all patients admitted with a fractured hip for surgery one year before and one year after the establishment of an OGT. Method: A total of 288 fractured hips were operated on during February 2004 to February 2005. From February 2005 the OGT was created, consisting of a Staff Grade and 2 Senior House Officers (junior residents), assisted part-time by a consultant. Patients were medically managed and optimised for theatre; 301 patients underwent surgery in the 1st year from Feb 2005 to 2006. The data was collected prospectively from admission, and entered onto a database. Results: Before the set up of the OGT only one-quarter (25%) of patients were operated on within 24hours compared to almost one-half of patients (44%) under the care of the OGT. Of the patients waiting more than 24hours, delay while waiting for special tests was similar but there was a significant difference in the percentages of patients delayed due to lack of theatre time and poor medical condition. Only 5% of patients under the care of the OGT were delayed due to medical co-morbidity compared with 44% when solely under orthopaedic care. Conclusion: Focused high-quality medical input provided by a specialist Orthogeriatric team resulted in significantly reduced delays to theatre for patients admitted with a fractured hip. This is in the context of our hip fracture population becoming increasingly frail with increasing medical problems and continuing pressures on operating time. In the environment of financial constraint, this study confirms that reduction in time to theatre, effective, appropriate investigation and lower complication rates are likely offset the cost of the team. This may provide a model for other units

Abstract

In aged trauma patients the basic prerequisite is early mobilization and full weight-bearing, as immobilization can trigger various complications such as pressure ulcers, pneumonia, urinary tract infections and others. Mortality of elderly patients increases significantly in fracture patients with partial weight-bearing compared to populations with total weight-bearing. Besides the limited physical strength in these patients, partial-weight bearing is however frequently used for the aftercare of hip fracture patients. Therefore, the present study aims to evaluate mobility of aged hip fracture patients with regards to weight-bearing and postoperative mobility.

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.

Introduction: Fracture of the osteoporotic hip is more common in people over the age of 74.

Purpose: To describe the co-operation between traumatologists and geriatric physicians in treating hip fractures among the elderly.

Materials and methods: Prospective study covering the number of referrals from Traumatology to Geriatrics in one year. We obtained data on age, sex, type of fracture and surgery, geriatric assessment and repercussion of this activity on the hospital.

Results: Over a period of 7 months in 2004, 120 patients were referred to Geriatrics, with a predominance of women and most with hip fractures. The intervention of the Geriatric Department consisted of detecting and compensating prior pathologies, adjusting medication, studying the fall, assessing the surgical risk and preparation for surgery, pain treatment, management of post-surgical complications (anaemia, malnutrition, pressure ulcers, infections, heart failure, etc.), early weight-bearing, detecting social risk and planning release from hospital. The repercussion of this work on the hospital translated into greater satisfaction among traumatologists, nursing staff and patients, more conditions diagnosed and treated and more complete release reports, thus improving ongoing care and shortening hospital stays.

Conclusions: Collaboration between the Traumatology and Geriatric Departments in treating geriatric patients admitted to Traumatology is cost-effective because it prevents complications, rationalises treatment, improves the patients’ functional status and shortens hospitalisation stays.

Aims

The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures.

There has been extensive research into neck of femur fractures in the elderly. Fragility non-hip femoral fractures share many of the same challenges [1]. Surgical management is complex, patients are frail and mortality rates have been reported as high as 38% [2]. Despite this, relatively little data is available evaluating the level of MDT care provided to non-hip femoral fractures. This audit aimed to evaluate the standard of MDT care provided for patients with non-hip femoral fractures according to the NHFD key performance indicators. The following fractures were included in the dataset: distal femoral, femoral shaft and peri-prosthetic femoral. Patients under 65 were excluded. Data was retrospectively collected using post-operative and medical documentation. Performance was assessed according to five key performance indicators:. Did orthogeriatrics review the patient within 72-hours?. Was surgery performed within 36-hours?. Was the patient weight bearing post-operatively?. Was a confusion assessment completed?. Was the patient discharged home?. 38 patients met the inclusion criteria. 84% of patients were seen by orthogeriatrics within 72 hours of admission. 32% of patients were operated on within 36-hours of admission, with time to theatre exceeding 36-hours in 92% of peri-prosthetic fractures. 37% of patients were not advised to full weight bear post operatively. 84% of patients received a confusion assessment whilst 61% of patients were discharged to their prior place of living. Our results suggest that non-hip femoral fractures do not receive the same standard of MDT care as neck of femur fractures. Greater prioritisation of resources should be given to this patient subset so that care is equivalent to hip-fracture patients. Time to surgery is a particular area for improvement, particularly in peri-prosthetic fractures, a trend that is mirrored nationally. Greater emphasis should be placed on encouraging full-weight bearing post-operatively to prevent post-surgical complications

Aims. This study aimed to identify risk factors (patient, healthcare system, and socioeconomic) for mortality after hip fractures and estimate their relative importance. Further, we aimed to elucidate mortality and survival patterns following fractures and the duration of excess mortality. Methods. Data on 37,394 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked to data from the Norwegian Patient Registry, Statistics Norway, and characteristics of acute care hospitals. Cox regression analysis was performed to estimate risk factors associated with mortality. The Wald statistic was used to estimate and illustrate relative importance of risk factors, which were categorized in modifiable (healthcare-related) and non-modifiable (patient-related and socioeconomic). We calculated standardized mortality ratios (SMRs) comparing deaths among hip fracture patients to expected deaths in a standardized reference population. Results. Mean age was 80.2 years (SD 11.4) and 67.5% (n = 25,251) were female. Patient factors (male sex, increasing comorbidity (American Society of Anesthesiologists grade and Charlson Comorbidity Index)), socioeconomic factors (low income, low education level, living in a healthcare facility), and healthcare factors (hip fracture volume, availability of orthogeriatric services) were associated with increased mortality. Non-modifiable risk factors were more strongly associated with mortality than modifiable risk factors. The SMR analysis suggested that cumulative excess mortality among hip fracture patients was 16% in the first year and 41% at six years. SMR was 2.48 for the six-year observation period, most pronounced in the first year, and fell from 10.92 in the first month to 3.53 after 12 months and 2.48 after six years. Substantial differences in median survival time were found, particularly for patient-related factors. Conclusion. Socioeconomic, patient-, and healthcare-related factors all contributed to excess mortality, and non-modifiable factors had stronger association than modifiable ones. Hip fractures contributed to substantial excess mortality. Apparently small survival differences translate into substantial disparity in median survival time in this elderly population. Cite this article: Bone Joint J 2022;104-B(7):884–893

Aims. The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines). Methods. The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up. Results. Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals. Conclusion. This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system. Cite this article: Bone Jt Open 2023;4(9):676–681

Osteoporosis is a disease when bone mass and tissue is lost, with a consequent increase in bone fragility and increase susceptibility to develop fracture. The osteoporosis prevalence increases markedly with age, from 2% at 50 years to more than 25% at 80 years. 1. in women. The vast majority of distal radius fractures (DRFs) can be considered fragility fractures. The DRF is usually the first medical presentation of these fractures. With an aging population, all fracture clinics should have embedded screening for bone health and falls risk. DRF is the commonest type of fracture in perimenopausal women and is associated with an increased risk of later non-wrist fracture of up to one in five in the subsequent decade. 2. . According to the national guidelines in managing the fragility fractures of distal radius with regards the bone health review, we, as orthopedic surgeons, are responsible to detect the risky patients, refer them to the responsible team to perform the required investigations and offer the treatment. We reviewed our local database (E-trauma) all cases of fracture distal radius retrospectively during the period from 01/08/2019 to 29/09/2019. We included total of 45 patients who have been managed conservatively and followed up in fracture clinic. Our inclusion criteria was: women aged 65 years and over, men aged 75 years and over with risk factors, patients who are more than 50 years old and sustained low energy trauma whatever the sex is or any patient who has major risk factor (current or frequent recent use of oral or systemic glucocorticoids, untreated premature menopause or previous fragility fracture). We found that 96% of patients were 50 years old or more and 84% of the patients were females. 71% of patients were not referred to Osteoporosis clinic and 11% were already under the orthogeriatric care and 18% only were referred. Out of the 8 referred patients, 3 were referred on 1st appointment, 1 on the 3rd appointment, 1 on discharge from fracture clinic to GP again and 3 were without clear documentation of the time of referral. We concluded that we as trust are not compliant to the national guidelines with regards the osteoporosis review for the DRF as one of the first common presentations of fragility fractures. We also found that the reason for that is that there is no definitive clear pathway for the referral in our local guidelines. We recommended that the Osteoporosis clinic referral form needs to be available in the fracture clinic in an accessible place and needs to be filled by the doctor reviewing the patient in the fracture clinic in the 1st appointment. A liaison nurse also needs to ensure these forms have been filled and sent to the orthogeriatric team. Alternatively, we added a portal on our online database (e-trauma), therefore the patient who fulfils the criteria for bone health review should be referred to the orthogeriatric team to review

Background. Polypharmacy of elderly trauma patients entails further difficulties in addition to the fracture treatment. Impaired renal function, altered metabolism and drugs that are potentially delirious or inhibit ossification, are only a few examples which must be carefully considered for the medication in elderly patients. The aim of this study was to investigate, if medication errors could be prevented by orthogeriatric comanagement compared to conventional trauma treatment. Material and methods. In a superregional traumacenter based on two locations in Munich, all patients ≥ 70 years with proximal femur fracture were consecutively recorded in a period of 3 months. After the end of the treatment the medical records of each patient were analyzed. At the hospital location 1 the treatment was carried out without orthogeriatric comanagement, at the hospital location 2 with this concept (DGU-certified orthogeriatric center). In addition to the basic medication all newly added drugs were recorded as well as changes in the medication plan and also wether treatment was carried out by the geriatrician or the trauma surgeon. Based on the START / STOPP criteria for the medication of geriatric patients, we defined “no-go” drugs with the geriatrician of the orthogeriatric center which should be avoided in the orthogeriatric patient (including benzodiazepines, gyrase inhibitors, NSAID like Ibuprofen with impaired GFR). The statistical analysis was done with the chi-square-test (IBM SPSS Statistics 24). Results and conclusion. A total of 46 patients were included, 37 of them female and 9 male with an average age of 84,5 years (SD±6.8). At the location without a geriatrician (18 patients), a prescription of one or more “no-go” drugs was found in 9 patients, whereas in location 2 (28 patients) only in 3 patients (p=0.003). Besides that, at the location with the geriatrician, a change in the medication was made for 17 patients during their stay in hospital. This shows that with the fixed integration of the geriatrician into the trauma surgical team, errors in the medication of the patients could be significantly more frequent avoided or faster detected and corrected. Although this should not limit the responsibility of the rest of the team, there is no doubt about the importance of the interdisciplinary treatment of elderly trauma patients

Abstract. Introduction. The management of hip fractures has advanced on all aspects from prevention, specialised hip fracture units, early operative intervention and rehabilitation in line with increasing incidence in an aging population. Accurate data analysis on the incidence and trends of hip fractures is imperative to guide future management planning. Methods. A review of all articles published on mortality after hip fracture over a twenty year period (1999–2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 – 1998) and attempts to present trends and geographical variations over sixty years. Results. The mean age of patients sustaining hip fractures has increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% in 2010s. Intracapsular fractures have drecreased from 54% (1970s) to 49% (2000s) and 48% (2010s). Conclusion. Our study indicates that progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical expediency all playing a role in the improvements in mean age of hip fracture and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally indicating increased attention and commitment to an

Introduction. Aged trauma patients with proximal femur fractures are prone to various complications. They may be associated with their comorbidities which also need to be adressed. These complications limit the patient”s postoperative health status and subsequently their activity and independency. As an attempt to improve the postoperative management of aged hip fracture patients a better understanding of the postoperative condition in these patients is necessary. Therefore, this meta-analysis is intended to provide an overview of postoperative complications in the elderly hip fracture patients and to improve the understanding of an adequate postoperative management. Material and method. Medline was used to screen for studies reporting on the complication rates of hip fracture patients > 65 years. The search criteria were: “proximal femur fracture, elderly, complication”. In addition to surgical studies, internal medicine and geriatric studies were also included. Randomized studies, retrospective studies as well as observation studies were included. Furthermore, reoperation rates as well as treatment-related complications were recorded. The 1-year mortality was calculated as outcome parameter. Results. Overall 54 studies were enrolled, published between 2011 and 2016. The mean age of the 9812 patients was 81 years (65–99 years). Follow-up was at least one year. The reoperation rate after osteosynthesis of pertrochanteric femur fractures was 8.7%. The reoperation rate was dependent on the type of fracture and the surgical method. Pneumonia (9,5%) and urinary tract infections (27%) were the most common postoperative infections. With 23%, delirium was one of the most common medical complications. The 1-year mortality rate was 18.7%. Conclusion. Orthogeriatric patients represent a complex patient population. Addressing the special needs of elderly patients reduces postoperative complications. Establishing comanagement or orthogeriatric wards can also be helpful to manage comorbidities and postoperative complications. It is important to not only choose the proper surgical procedure but to monitor orthogeriatric patients closely during their hospitalization

Fractures of the neck of femur are common in the older adult with significant morbidity and mortality rates. This patient cohort is associated with frailty and multiple complex medical and social needs requiring a multidisciplinary team to provide optimal care. The aim of this study was to assess the outcomes at 5 years following implementation of a collaborative service between the Orthopaedic and Geriatric departments of Southland Hospital in 2012. Retrospective data was collected for patients aged 65 years and older who were admitted with a fragility hip fracture. Data was collated for 2011 (pre-implementation) and 2017 (post-implementation). Demographics and ASA scores were recorded. We assessed 30-day and 1-year mortality, surgical data, length of stay and complications. There were 74 patient admissions in 2011 and 107 in 2017. Mean age at surgery was 84.2 years in 2011 and 82.6 years in 2017 (p>0.05). Between the 2011 and 2017 groups there has been a non-significant reduction in length of stay on the orthopaedic ward (9.8 days vs 7.5 days, p=0.138) but a significant reduction in length of stay on the rehabilitation ward (19.9 vs 9 days, p<0.001). There was a significant decrease in frequency of patients with a complication (71.6% vs 57%, p=0.045) and a marginal reduction in number of complications (p=0.057). Through logistic regression controlling for age, sex and ASA score, there was a reduction in the odds of having a complication by 12% between 2011 and 2017 (p<0.001). There was no difference in mortality between the groups. The orthogeriatric model of care at Southland Hospital appears to have reduced both the frequency of complications and length of stay on the rehabilitation ward 5 years after its implementation. This is the first study in New Zealand demonstrating medium-term post-implementation follow-up of what is currently a nationally accepted standard model of care

Introduction. Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC). Materials & Methods. This cohort study evaluates the management of geriatric (≥65years) open ankle fractures in a MTC (November 2020–November 2022). The method, timing(s) and personnel involved in surgical care were assessed. Weightbearing status over the treatment course was monitored. Patient frailty was measured using the clinical frailty score (CFS). Results. There were 35 patients, mean age 77 years (range 65–97 years), 86% female. Mean length of admission in the MTC was 26.4 days (range 3–78). Most (94%) had a low-energy mechanism of injury. Only 57% of patients underwent one-stage surgery (ORIF n=15, hindfoot nail n=1, external frame n=4) with 45% being permitted to fully weightbear (FWB). Eleven (31.4%) underwent two-stage surgery (external fixator; ORIF), with 18% permitted to FWB. Of those patients with pre-injury mobility, 12 (66%) patients were able to FWB following definitive fixation. Delay in weightbearing ranged from 2–8weeks post-operatively. Seven patients (20%) underwent an initial Orthoplastic wound debridement. Ten patients (28.6%) required plastic surgery input (split-skin grafts n=9, local or free flaps n=3), whereby four patients (40%) underwent one stage Orthoplastic surgery. Eighteen (51.4%) patients had a CFS ≥5. Patients with a CFS of ≥7 had 60% 90-day mortality. Only 17% patients had orthogeriatrician input during admission. Conclusions. These patients have high frailty scores, utilise a relatively large portion of resources with multiple theatre attendances and protracted ward occupancy in an MTC. Early FWB status needs to be the goal of treatment, ideally in a single-staged procedure. Poor access to orthogeriatric care for these frail patients may represent healthcare inequality

Background: Recognising the need for orthogeriatric input for fractured neck of femur patients, as evident from recent studies, has been established fact for some time now. Although, most studies suggest a healthcare model involving an orthogeriatric service of some degree, usually a visiting physician or a post-operative rehabilitation setup, we highlight an innovative strategy involving a dedicated in-house orthogeriatric team providing a high-level of care based in a stabilisation unit. Since the realisation back in 2004 that the Relative Risk for Mortality in patients with fractured neck of femurs was 164.6, CI (130.5–204.8) compared to the expected level of 100, a series of changes were introduced to combat this. Methods: Within the orthopaedic department a trauma stabilisation unit (TSU) was setup with a dedicated orthogeriatric service and the early warning score (EWS) system was implemented. This was used to identify patients requiring higher levels of care and thus transfer to TSU. Results: The 2007 Relative Risk for Mortality for hip fractures stands at 92.4, CI (66–125.9) suggesting a reduction of 44% in mortality. Furthermore, there has been no significant change in age, co-morbidity or delay to surgery over this period. Discussion: The presence of an orthogeriatric service which dedicates itself to patient optimisation pre-operatively and post-operative recovery has immensely improved the outlook on this frail population. The increase level of nursing care with a ratio of 1:2 and implementation of the EWS system again adds to improved patient care and outcome. Thus we strongly advocate that the development of such a care model within trauma & orthopaedics is essential in improving the service our patients receive

Literature suggests that joint orthopaedic and geriatric care, and geriatric orthopaedic rehabilitation units, would provide best care for fractured neck of femur (NOF) patients. These are often elderly frail patients with concurrent illnesses and co-morbidities who also have a fracture. There is to date no quantitative data. This completed audit quantifies the care provided on the orthopaedic wards in the first phase solely by orthopaedic team, and in the repeat phase with additional regular geriatric input from an orthogeriatric senior house officer (SHO) and consultant geriatrician ward rounds. A retrospective audit of fractured NOF patients admitted to acute orthopaedic wards under orthopaedics and treated operatively. The first phase analysed 72 patients with sole orthopaedic care. The repeat phase analysed 25 patients after the introduction of an orthogeriatric SHO and geriatric ward rounds. The first audit phase of orthopaedic care alone found that 50% of patients were reviewed each day of the first post op seven-day week. The mean number of reviews in the post-op week was three. A total of 58% patients were operated on the next day. A minority never had post-op bloods or x-rays prior to discharge from the acute bed. Ad hoc medical input by referral occurred in 50% of patients. The repeat audit of combined orthogeriatric care found that 75% of patients were reviewed each day in the post-op week. The mean number of reviews in the post-op week rose to five. Similar to the first phase, 59% proceeded to next day surgery with combined care. All patients had timely bloods and x-rays before discharge from the acute bed. Medical input rose to 80% due to regular ward rounds, and ad hoc referrals decreased in quantity whilst increased in quality. Length of stay and mortality were reduced. The clinical risk of fractured NOF patients was reduced on the appointment of an orthogeriatric SHO in combination with formal reviews by consultant geriatrician. Further models of care are being evaluated. This audit adds evidence that joint care is better for these usually elderly and co-morbid patients

For some years, there has been vast international interest in creating models for joint efforts between geriatricians and orthopedic surgeons. We present data from two such models. For the first time in Denmark, the Department of Orthopedics Bispebjerg University Hospital (BUP) recruited two full-time geriatricians in September 2009. They were assigned an independent unit meant for severely ill orthopaedic patients with high comorbidity and polypharmacy. These two geriatricians had, during the previous two years, consulted another orthopaedic department at Gentofte University Hospital (GUH) in a neighbouring community three times a week. The aim of their intervention was then to optimize treatment for comorbidity, to clarify indication of acute fall-assessment, osteoporosis diagnosis and treatment, presence of delirium and dementia. Methods. A total of 1344 hip fracture patients (age 70 years) divided into three populations were included in this study. Mortality data were collected from the Danish Civil Registry. Population 1 (P1), n = 645 was included at GUH from January 1, 2006 to December 31, 2007. During the entire period, the patients had access to a senior consultant in geriatric medicine three times a week. In this population, the majority of patients were assessed for dementia (n = 636), delirium (n = 627) and Barthel Index (Barthel100) at admission (n = 394). Population 2 (P2), n = 381 included at BUH from September 1, 2009 until July 8, 2010 with orthogeriatric access. Population 3 (P3), n = 318 were included at BUH from September 28, 2008 until August 31, 2009 with no orthogeriatric access. Age mean (SD): P1 84.7 (6.8), P2 85.5 (7.3), P3 85.3 (14.3) P = 0.1(ANOVA) Sex ratio: females/males: P1 0.73/0.27, P2 0.80/0.20, P3 0.75/0.25 P = 0.09 Chi square). Results. In-hospital mortality rate: P1 4.8%, P2 6.3%, P3 9.1% P = 0.03 (Chi square). Three month mortality: In P1 dementia, delirium and Barthel Index (below 50 versus above 50) were all strong predictors: No dementia: 53/383 (13.8%) versus dementia present 68/253 (26.9%) died, P = 0001 (log-rank test). No delirium 69/456 (15.1%) versus delirium present 47/171 (27.5%) died F = 0.0004 (log-rank test) Barthel Index 50 38/372 (10.2%) versus Barthel<50 7/22 (31.8%) died P = 0.0004. Conclusion. This paper reports data from two different models with orthogeriatric service. Our data present delirium, dementia and Barthel Index to be very strong predictors for three month mortality (P1). Despite the time needed to implement a new orthogeriatric unit and the fact that the geriatricians only assessed a proportion of hip fracture patients, in-hospital mortality was reduced significantly for the total hip-fracture population (P2) within the first 10 months

Aims. To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries. Patients and Methods. The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients. Results. Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures. . Conclusion. Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. . Cite this article: Bone Joint J 2017;99-B:1677–80

The August 2015 Trauma Roundup. 360 . looks at: Thromboprophylaxis not required in lower limb fractures; Subclinical thyroid dysfunction and fracture risk: moving the boundaries in fracture; Posterior wall fractures refined; Neurological injury and acetabular fracture surgery; Posterior tibial plateau fixation; Tibial plateau fractures in the longer term; Comprehensive orthogeriatric care and hip fracture; Compartment syndrome: in the eye of the beholder?

Osteoporosis is common in elderly patients admitted to orthopaedic units with fractures. Fragility fractures place a large burden on health expenditure. Orthopaedic units are in a position to identify patients who require bone density assessment and possible treatment of osteoporosis. Previous surveys of orthopaedic surgeons have shown a wide variance in their perceived role in this. This study was a retrospective note review of 305 patients aged over 55 years with a fragility fracture, who were admitted under the orthopaedic service of eight New Zealand hospitals. Notes from any subsequent rehabilitation unit admission were also reviewed, if available. The mean age was 80.6 years (range 55–104). Seventy seven percent were female. The most common fracture was of the hip (61.6%). Two hundred and thirty-six patients (77.4%) were not taking osteoporosis medication at time of admission, 2.5% of these had a bone mineral density assessment ordered and 11.9% had osteoporosis treatment started, giving a combined intervention rate (investigation or treatment) of 14.4%. A visiting orthogeriatric service initiated treatment in 82.1% of cases. Osteoporosis was listed on the discharge summary in 31.8% of patients who were taking osteoporosis treatment on admission and in 10.7% of patients who had treatment started. Management of osteoporosis is mostly neglected by New Zealand orthopaedic units. This is similar to published data from other countries. Hospitals with the highest rates of osteoporosis intervention had an orthogeriatric service initiating the majority of treatment. Treatment started by the orthopaedic staff was not optimal. Osteoporosis is not identified in most documentation generated by the orthopaedic units

Introduction. The length of hospital stay following a hip fracture has decreased significantly during the past decades. Knowing that a hip fracture patient is often one with several comorbidities and high mortality, is it possible to further decrease the length of stay without compromising the quality of care?. Setting. Prior to November 2007 a hip fracture patient at Svendborg Hospital would be admitted to the orthopedic department. Postoperatively the patient would be treated by the orthopedic surgeons. If needed a geriatric consult could occur. If the patient was eligible she could be transferred to the geriatric department for further rehabilitation. After November 2007 eight orthopedic beds were dedicated to hip fracture patients, in an orthogeriatric setting. The patient was treated operatively by the orthopedic surgeons, and then a geriatric consultant was responsible for the rest of the stay. Nurses and therapists were dedicated to the care of hip fracture patients, and had recieved special training regarding. The patient would stay in the same bed throughout the hospitalisation. Material. 224 consecutive hip fracture patients prior to November 2007 treated in a classic orthopedic department compared to 224 consecutive hip fracture patients after November 2007 treated in the orthogeriatic department. Of the 224 patients treated prior to November 2007 117 were eventually transferred to the geriatric department. Result. the overall mean hospital stay in the classic orthopedic department was 17.5 days (range 2–58 days, 95% CI 15.9–18.8 days). Patients (N=107), who were not transferred to the geriatric department had a mean of 8,7 days, whereas those who were transferred had a mean stay of 25,5 days. After November 2007 the overall mean length of stay was 11.5 days (range 1–38, 95% CI 10.5–11.9 days). The hip fracture patients spent 1,388 less days in hospital when admitted to the orthogeriatric setting as compared to the classic orthopedic setting. The 30 day mortality was 11,3% in the group prior to November 2007 compared to 9,8% in the group after November 2007. Conclusion. Changing the setting in which hip fracture patients are treated, significantly reduces the overall length of stay (p<0.0000), without compromising mortality. It involves an interdisciplinary setting with dedicated nurses and therapists. The hip fracture patient is first and foremost regarded as a geriatric patient and thus treated postoperatively by geriatric consultants

Aims

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

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Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

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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.

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Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Total hip replacement (THR) is NICE recommended for a group of patients with neck of femur fracture (NOF) and guidance published in 2011. In our institution a Hip Fracture Program was established at this time to improve patient care. An audit of the Hip Fracture Program, appropriateness of THR and management following THR was undertaken and compared to NICE standards, set at 100%, and National Hip Fracture Database (NHFD) results. The case-notes for 53 patients (38 female, 15 male) undergoing THR for NOF between 2011 and 2013 were reviewed: median age 70 yrs (34–87), follow-up 28 months (3–57). All patients were initiated on a Hip Fracture Program. 92% were eligible for THR according to NICE guidance. Pre-operative pain management (67%), hourly assessment of pain in ED (4%), surgery with 48 hours (32%), pre-operative orthogeriatric review (58%) and intra-operative nerve block (38%) are areas for development, but most results are comparable to NHFD. Post-operative care is satisfactory with daily mobilisation (87%) and post-operative pain management (100%). No post-operative dislocation or infection was recorded. There was one case of post-operative DVT. This study highlights areas for improvement in hip fracture management and emphasises the benefits in implementing a Hip Fracture Program in this vulnerable patient population

A simple classification system, NOF complexity classification, was developed at the Great Western Hospital Trauma and Orthopaedic department, allowing stratification of resources. This is a four-group classification system, each group with two elements, firstly the patients medical fitness and secondly the complexity of the fracture. (C0=medically fit + simple fracture, C1=medically fit + complex fracture, C2=medically unfit + simple fracture, C3=medically unfit + complex fracture). Between June 2008 and June 2009, data was collected retrospectively for 290 patients during a weekly MDT meeting to enter data that has been gathered into a departmental database to monitor our performance. The outcomes that we looked for to test the validity of this classification are the thirty-day mortality, annual mortality and length of hospital stay all stratified by complexity. Results showed that there has been a strong correlation between the complexity classification and the 30-day and annual mortality with P values of 0.015 and 0.008 respectively. This resulted in a 30-day mortality of 4.4%, which is half the national average. Our average length of stay was equal to the national average of 23 days. This classification system has allowed an improvement in service by adapting a classification system, which is understood by both the Orthogeriatric and Orthopaedic teams

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This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year.

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Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population.

Introduction. Renal homeostasis has been shown to influence mortality after hip fractures; this is true for patients with both chronic kidney disease, and those who develop acute renal dysfunction after surgery. We have examined the influence of impaired renal function upon mortality and length of stay. We investigated this relationship through accurate mathematical modelling of available biochemistry data on a cohort of hip fracture patients. Methods. Complete data were available for 566 patients treated over a 27-month period. All patients had urea and creatinine checked on admission, and at 24–48 hours after surgery. Post-operative analgesia, fluid therapy, transfusion protocols and orthogeriatric reviews were standardised. Generalised Linear Models and correlation matrices were used. Cox-proportional hazards analyses investigated the association between serum concentrations of urea and creatinine on admission and length of stay and mortality after surgery. Results. The cohort included 427 females and 139 males (mean age 80.6 years, mean post-operative length of stay 19 days). 1-year mortality was 19.1%. Urea and creatinine were significantly, positively correlated with age (more significant for urea). After adjusting for age and sex, risk of mortality was positively related to serum concentrations of creatinine and marginally so for urea. Increased age and a male gender were associated with a higher mortality risk. Risk of discharge from trauma ward, length of stay on trauma ward, and overall length of stay were not related to levels of creatinine and urea at admission. Conclusions. This study shows a quantifiable correlation between renal dysfunction and NOF mortality. The low risk of survival with both male sex and raised creatinine identified this subgroup as the ‘most at risk’. Both age and gender are non-modifiable factors, so this subgroup may require a more targeted approach to the management of their fluid and electrolyte homeostasis

Aims

We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

Aim. A new multidisciplinary hip fracture pathway, based on national BOA and NICE guidance, was introduced in our institution to facilitate rapid preoperative medical optimisation and early surgery for patients with hip fractures. The aim of this audit was to assess its impact on patient care and outcomes. Method. A prospective audit of 161 patients admitted with a fractured neck of femur was conducted in the six months before (92 patients) and after (69 patients) implementation of the new pathway. Data included: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; and inpatient mortality rate. Significance was tested using Chi Squared, Fisher's exact and unpaired Student t-Tests. Results. The two groups of patients were equivalent in terms of age, male:female ratio, ASA grade and preoperative AMTS. In the six months after the introduction of the pathway, 85% of patients received a pre-operative medical assessment compared to 19% before (p=0.0001). Average TtG dropped from 91 to 19 hours (p=0.0001). LOS dropped from 24.8 days to 19.5 days (p=0.029). Furthermore, a significant reduction in mortality of 10% (14% before, 4% after, p=0.0336) was found, with an increase in the proportion of patients returning to their original place of accommodation (57% before, 80% after, p=0.0069). Whilst limited by theatre scheduling, there was an observed reduction in TtS of 6 hours (37 vs 31, p=0.0663). Conclusions. Rapid medical optimisation and prompt surgery can significantly reduce length of stay and inpatient mortality of patients with hip fractures. This is especially important in light of their often fragile physiological state and complex co-morbidities. Successful implementation of a multidisciplinary hip fracture pathway can increase the return of patients to their preoperative accommodation, thus maintaining their level of pre-morbid independence and potentially leading to significant future cost savings

Background: Dr Foster’s Good Hospital Guide 2005–2006 ranked University Hospitals of Leicester NHS Trust amongst the worst in UK for in-hospital mortality and time to theatre in hip fracture patients. The problem had been recognized in early 2005 and the Fracture Neck of Femur (FNOF) project was launched. This included an increase in trauma coordinators and clinical aides, regular orthogeriatric input, daily hip fracture operating lists, a separate hip fracture ward and a dedicated discharge nurse. Aim: The aim of this study was to assess the outcome of the FNOF project. Method: Data on mortality and length of stay was collected from the IM& T department and was cross referenced with the PCT database. Time to theatre data was collected from the trauma coordinators. Study period was five years from January 2003 to December 2007. Results: 3636 patients were admitted with a hip fracture in the five year period. The length of stay reduced from 31 days in 2005 to 19 days in 2007 (p< 0.001). The in-hospital mortality reduced from 17.0 % in 2005 to 11.3% in 2007 (p< 0.01). 1 year mortality dropped from 36.9% to 27.3% (p< 0.001). The 30 day and 4 month mortality were also reduced but this was not statistically significant. 85% of patients had surgery within 48 hours in 2007 as compared to 47% in 2005–06. Conclusions: The FNOF project was successful in reducing In-hospital and 1 year mortality, length of stay and time to theatre. However, the 30 day mortality did not show a significant reduction. In-hospital mortality is not a good comparator of hospital performance as it depends on length of stay; 30 day mortality would be more accurate. The national hip fracture database can be used to obtain accurate data for future studies

Aims

This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time.

Background: A good hospital guide published in 2006 identified high in-hospital mortality rates in fracture neck of femur patients at the University Hospitals of Leicester NHS trust. The trust was identified as the worst in the country in terms of the percentage of patients having surgery within the recommended 48 hours from admission. The problem had already been identified and a ‘Fracture Neck of femur project’ was launched in January 2006 to improve outcomes in these patients. This included the introduction of trauma coordinators and clinical aides who prepared patients for surgery, a separate fracture neck of femur ward, a discharge nurse, dedicated hip fracture lists and pre and post operative orthogeriatric input. Aim: The aim of this study was to assess the impact of the fracture neck of femur project. Methods: Data on admissions, time to theatre, length of stay and mortality was collected for 3400 patients admitted with fracture neck of femur between January 2003 and September 2007. Mortality rates, length of stay and time to theatre were compared before and after the introduction of the fracture neck of femur project. Results: The length of stay reduced from 32 days to 18 days in 2007 (p< 0.01). The in-hospital mortality reduced from 16.6 % in 2003 to 10.7% in 2007 (p< 0.01). 30 day mortality showed a minor reduction from 12.4% in 2003 to 11.4% in 2007 (p=0.6). 95% of patients had surgery within 48 hours as compared to 47% in 2005–06 and 85% in 2006–07. Conclusions: The high in-hospital mortality rates were reduced. The length of stay was also reduced by effective discharge planning. Measures to reduce time to theatre were highly successful. However, the 30 day mortality did not show a significant reduction. We conclude that in hospital mortality is not a good comparator of hospital performance. 30 day mortality would be more accurate

Aims

The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures.

Aim: To assess the impact of a proforma pathway on the care of patients following fractured neck of femur at Maidstone General Hospital compared to the gold standard set out in the British Orthopaedic Association and British Geriatric Society Blue Book – The Care of Patients with a Fragility Fracture. Objectives: Initial audit of care prior to the introduction of the Proforma. Development of a multidisciplinary care pathway and proforma following BOA Standards for Trauma (BOAST) and National Hip Fracture Database (NHFD) guidelines. Re-audit of care following implementation of the proforma. Identification of areas for development to implement in the NHS (Institute for Innovation and Improvement) Rapid Improvement Program – Focus on Fractured Neck of Femur. Background: The recent publication of the BOA and BGS Blue Book guidelines for care of patients with fragility fractures has defined a gold standard for the care of these patients. This has highlighted the areas of care that are commonly suboptimal and defined the requirements of a department providing ideal care. Both this, and the introduction of the NHFD and the resultant requirements for data collection and monitoring led us to develop a proforma for management and data collection. Methods: An initial audit of care was performed. Notes were reviewed retrospectively for 62 patients and results were compared to the gold standard. In June 2008 the proforma was implemented and data collected for reaudit (n=48). Direct comparison and statistical analysis was performed for the two groups of patients. Results: Comparison of the two audit groups shows dramatic and highly statistically significant differences in a number of areas of patient care, notably: mortality rates; appropriate A& E investigation and treatment; documentation of correct diagnosis and social history; mental test scoring; time to ward admission; time to surgery and osteoporosis treatment. Discussion: The lack of a ring fenced, dedicated trauma ward leads to patients being admitted to outlying wards following fractured neck of femur. These wards are less likely to be as well equipped to deal with the unique requirements of these patients, which may explain the consistent problems with pressure area care and delay in discharge. A strong recommendation for gold standard care is the provision of an orthogeriatric service with regular medical review both pre- and post-operatively. Currently no such dedicated service exists at Maidstone and this affects both the treatment of acute medical problems and the provision of falls investigation and treatment. The introduction of the pathway has clearly benefitted the management of this difficult problem. With the support of the Rapid Improvement Program, further beneficial changes can be made to the care of patients following fractured NOF

Introduction. Over 300,000 patients present with fragility fractures each year. Following a hip fracture, the 30 days mortality is around 8.3 to 9.3%. Mortality increases to 20–24% after the first year and this risk may persist for at least 5 years. The most significant variables that influence mortality are age, gender, fracture type, prefracture residence, prefracture mobility and ASA scores. Common reported postoperative complications responsible for mortality in hip fracture patients include; heart failure, bronchopneumonia and infections. Most of the studies in the literature focus on management variables influencing mortality rather than the encountered postoperative medical problems leading to death. The aim of this study is to retrospectively analyze the postoperative medical complications which led to death in a cohort of patients, following a hip fracture. Methodology. This is a retrospective analysis of a cohort of 82, out of 648, patients with hip fractures who died over a period of 2 years (December 2006–January 2009). Forty nine females and 33 males (ratio 1.5:1) were included in the study with a mean age of 87.8 years (range 59–98 years). For mortality analysis, patients' co-morbidities and medical events leading to death were categorized according to the involved organ system. This included cardiovascular, respiratory, renal, gastrointestinal, neurological and musculoskeletal systems). The timing and decision of DNAR and palliation was noted for each patient. The 30 days and the overall mortality were the set outcome measures to be reviewed. Results. The 30 days mortality was 9.4% and 13.6% overall. The majority of patients had multiple co-morbidities; 75.6% had cardiac morbidities, 28% had respiratory problems, 19.5% had renal problems, 22% had neurological problems, 22% had endocrine problems and 34.1% had miscellaneous problems including cancer in 9 patients. Out of the 82 patients, 67 died postoperatively and 15 died preoperatively. Of the 67 postoperative deaths the main reported events that led to death were; respiratory in 59.7% (90% of which had chest infection), cardiac in 29.9% (60% of which had pulmonary edema) and sepsis in 35.8% (62.5% of which had chest infection). Of the 15 preoperative deaths the lead cause of death was the respiratory problems, reported in 73.3%, of which 81.8% were due to chest infection. X% of the patients had DNAR decision and x% were palliated. Documented decisions for DNAR and palliation were done by a senior house officers and registrars in the majority of cases (x%). Conclusion. The majority of deaths in our series were related to chest infection (54.9%), cardiac failure (15.9%) and sepsis mainly secondary to chest infection (32.9%, of which 62.9% were related to chest infection). Increased awareness of the encountered medical problems that can lead to death consolidates the need of a pre and postoperative orthogeriatric input to optimize these frail patients

Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

Aims

The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks.

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This study aims to assess the feasibility of conducting a pragmatic, multicentre randomized controlled trial (RCT) to test the clinical and cost-effectiveness of an informal caregiver training programme to support the recovery of people following hip fracture surgery.

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A proximal femur fracture (PFF) is a common orthopaedic presentation, with an incidence of over 25,000 cases reported in the Australian and New Zealand Hip Fracture Registry (ANZHFR) in 2018. Hip fractures are known to have high mortality. The purpose of this study was to determine the utility of the Clinical Frailty Scale (CFS) in predicting 30-day and one-year mortality after a PFF in older patients.

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The aim of this study was to describe variation in hip fracture treatment in Norway expressed as adherence to international and national evidence-based treatment guidelines, to study factors influencing deviation from guidelines, and to analyze consequences of non-adherence.

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Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients.

Aims

The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures.

Aims

The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.

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COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographics and outcomes of patients treated during lockdown to a matched period from 2019. Findings have important implications for service development.

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Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic.

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This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures.

Aims

There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

Aims

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

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The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital.

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Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group.

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COVID-19 has changed the practice of orthopaedics across the globe. The medical workforce has dealt with this outbreak with varying strategies and adaptations, which are relevant to its field and to the region. As one of the ‘hotspots’ in the UK , the surgical branch of trauma and orthopaedics need strategies to adapt to the ever-changing landscape of COVID-19.

Aims

Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Aims

The aim of this study was to assess the feasibility of conducting a full-scale, appropriately powered, randomized controlled trial (RCT) comparing internal fracture fixation and distal femoral replacement (DFR) for distal femoral fractures in older patients.

We retrospectively reviewed 2989 consecutive patients with a mean age of 81 (21 to 105) and a female to male ratio of 5:2 who were admitted to our hip fracture unit between July 2009 and February 2013. We compared weekday and weekend admission and weekday and weekend surgery 30-day mortality rates for hip fractures treated both surgically and conservatively. After adjusting for confounders, weekend admission was independently and significantly associated with a rise in 30-day mortality (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.02 to 1.9; p = 0.039) for patients undergoing hip fracture surgery. There was no increase in mortality associated with weekend surgery (OR 1.2, 95% CI 0.8 to 1.7; p = 0.39). All hip fracture patients, whether managed surgically or conservatively, were more likely to die as an inpatient when admitted at the weekend (OR 1.4, 95% CI 1.02 to 1.80; p = 0.032), despite our unit having a comparatively low overall inpatient mortality (8.7%). Hip fracture patients admitted over the weekend appear to have a greater risk of death despite having a consultant-led service.

Cite this article: Bone Joint J 2014;96-B:373–8.

Objectives

The National Hip Fracture Database (NHFD) publishes hospital-level risk-adjusted mortality rates following hip fracture surgery in England, Wales and Northern Ireland. The performance of the risk model used by the NHFD was compared with the widely-used Nottingham Hip Fracture Score.

Hip fracture is a common injury associated with high mortality, long-term disability and huge socio-economic burden. Yet there has been relatively little research into best treatment, and evidence that has been generated has often been criticised for its poor quality. Here, we discuss the advances made towards overcoming these criticisms and the future directions for hip fracture research: how co-ordinating existing national infrastructures and use of now established clinical research networks will likely go some way towards overcoming the practical and financial challenges of conducting large trials. We highlight the importance of large collaborative pragmatic trials to inform decision/policy makers and the progress made towards reaching a consensus on a core outcome set to facilitate data pooling for evidence synthesis and meta-analysis.

These advances and future directions are a priority in order to establish the high-quality evidence base required for this important group of patients.

Cite this article: Bone Joint J 2015;97-B:875–9.

Aims

Rates of mortality as high as 25% to 30% have been described following fractures of the odontoid in the elderly population. The aim of this study was to examine whether easily identifiable variables present on admission are associated with mortality.

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

The National Institute for Health and Clinical Excellence (NICE) guidelines from 2011 recommend the use of cemented hemi-arthroplasty for appropriate patients with an intracapsular hip fracture. In our institution all patients who were admitted with an intracapsular hip fracture and were suitable for a hemi-arthroplasty between April 2010 and July 2012 received an uncemented prosthesis according to our established departmental routine practice. A retrospective analysis of outcome was performed to establish whether the continued use of an uncemented stem was justified. Patient, surgical and outcome data were collected on the National Hip Fracture database. A total of 306 patients received a Cathcart modular head on a Corail uncemented stem as a hemi-arthroplasty. The mean age of the patients was 83.3 years (sd 7.56; 46.6 to 94) and 216 (70.6%) were women. The mortality rate at 30 days was 5.8%. A total of 46.5% of patients returned to their own home by 30 days, which increased to 73.2% by 120 days. The implant used as a hemi-arthroplasty for intracapsular hip fracture provided satisfactory results, with a good rate of return to pre-injury place of residence and an acceptable mortality rate. Surgery should be performed by those who are familiar with the design of the stem and understand what is required for successful implantation.

Cite this article: Bone Joint J 2013;95-B:1538–43.

Aims

In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip.

We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox’s regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in Clostridium difficile colitis (p = 0.017), deep wound infection (p = 0.043) and gastrointestinal haemorrhage (p = 0.033). There were no differences in any patient risk factors (except the prevalence of chronic obstructive pulmonary disease), cause of death and length of stay before and after intervention. The underlying mechanisms are unclear, but may include improved efficiency and medical contact time.

These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect.

The lack of a consensus for core health outcomes that should be reported in clinical research has hampered study design and evidence synthesis. We report a United Kingdom consensus for a core outcome set (COS) for clinical trials of patients with a hip fracture.

We adopted a modified nominal group technique to derive consensus on 1) which outcome domains should be measured, and 2) methods of assessment. Participants reflected a diversity of perspectives and experience. They received an evidence synthesis and postal questionnaire in advance of the consensus meeting, and ranked the importance of candidate domains and the relevance and suitability of short-listed measures. During the meeting, pre-meeting source data and questionnaire responses were summarised, followed by facilitated discussion and a final plenary session. A COS was determined using a closed voting system: a 70% consensus was required.

Consensus supported a five-domain COS: mortality, pain, activities of daily living, mobility, and health-related quality of life (HRQL). Single-item measures of mortality and mobility (indoor/outdoor walking status) and a generic multi-item measure of HRQL - the EuroQoL EQ-5D - were recommended. These measures should be included as a minimum in all hip fracture trials. Other outcome measures should be added depending on the particular interventions being studied.

Cite this article: Bone Joint J 2014; 96-B:1016–23.

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls.

Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively.

Cite this article: Bone Joint J 2014;96-B:366–72.

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

Between January 2000 and December 2007, 31 patients 90 years of age or older underwent total hip replacement at our hospital. Their data were collected prospectively. The rate of major medical complications was 9%. The surgical re-operation rate was 3%. The requirement for blood transfusion was 71% which was much higher than for younger patients. The 30-day, one-year and current mortality figures were 6.4% (2 of 31), 9.6% (3 of 31) and 55% (17 of 31), respectively, with a mean follow-up for the 14 surviving patients of six years. Cox’s regression analysis revealed no significant independent predictors of mortality. Only 52% of patients returned immediately to their normal abode, with 45% requiring a prolonged period of rehabilitation.

This is the first series to assess survival five years after total hip replacement for patients in their 90th year and beyond. Hip replacement in the extreme elderly should not be discounted on the grounds of age alone, although the complication rate exceeds that for younger patients. It can be anticipated that almost half of the patients will survive five years after surgery.