Aims. Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure. Methods. We conducted a prospective observational cohort study over a one-year period from December 2021 to December 2022. Patient demographic details, biochemical results, and haemodynamic observations were taken from electronic medical records. Statistical analysis was conducted with the Cox proportional hazards model, and the effects of independent variables estimated with the Wald statistic. Kaplan-Meier survival curves were estimated with the log-rank test. Results. A total of 528 patients were identified as suitable for inclusion. On multivariate analysis, postoperative hypotension of a systolic blood pressure (SBP) < 90 mmHg two to 24 hours after surgery showed an increased hazard ratio (HR) for 30-day mortality (HR 4.6 (95% confidence interval (CI) 2.3 to 8.9); p < 0.001) and was an independent risk factor accounting for sex (HR 2.7 (95% CI 1.4 to 5.2); p = 0.003), age (HR 1.1 (95% CI 1.0 to 1.1); p = 0.016), American Society of Anesthesiologists grade (HR 2.7 (95% CI 1.5 to 4.6); p < 0.001), time to theatre > 24 hours (HR 2.1 (95% CI 1.1 to 4.2); p = 0.025), and preoperative anaemia (HR 2.3 (95% CI 1.0 to 5.2); p = 0.043). A preoperative SBP of < 120 mmHg was close to achieving significance (HR 1.9 (95% CI 0.99 to 3.6); p = 0.052). Conclusion. Our study is the first to demonstrate that postoperative hypotension within the first 24 hours is an independent risk factor for 30-day mortality after hip fracture surgery. Clinicians should recognize patients who have a SBP of < 90 mmHg in the early postoperative period, and be aware of the increased mortality risk in this specific cohort who may benefit from a closer level of monitoring and early intervention. Cite this article: Bone Joint J 2024;106-B(2):189–194

Aims. 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. Methods. This will be a mixed-methods feasibility RCT, recruiting 60 patients following hip fracture surgery and their informal caregivers. Patients will be randomized to usual NHS care, versus usual NHS care plus a caregiver-patient dyad training programme (HIP HELPER). This programme will comprise of three, one-hour, one-to-one training sessions for the patient and caregiver, delivered by a nurse, physiotherapist, or occupational therapist. Training will be delivered in the hospital setting pre-patient discharge. It will include practical skills for rehabilitation such as: transfers and walking; recovery goal setting and expectations; pacing and stress management techniques; and introduction to the HIP HELPER Caregiver Workbook, which provides information on recovery, exercises, worksheets, and goal-setting plans to facilitate a ‘good’ recovery. After discharge, patients and caregivers will be supported in delivering rehabilitation through three telephone coaching sessions. Data, collected at baseline and four months post-randomization, will include: screening logs, intervention logs, fidelity checklists, quality assurance monitoring visit data, and clinical outcomes assessing quality of life, physical, emotional, adverse events, and resource use outcomes. The acceptability of the study intervention and RCT design will be explored through qualitative methods with 20 participants (patients and informal caregivers) and 12 health professionals. Discussion. A multicentre recruitment approach will provide greater external validity across population characteristics in England. The mixed-methods approach will permit in-depth examination of the intervention and trial design parameters. The findings will inform whether and how a definitive trial may be undertaken to test the effectiveness of this caregiver intervention for patients after hip fracture surgery. Cite this article: Bone Jt Open 2021;2(11):909–920

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. Methods. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results. Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion. There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720

Aims. The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods. This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results. We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion. The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications. Cite this article: Bone Joint J 2024;106-B(8):849–857

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

Aims. This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods. Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I. 2. statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results. There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion. Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Aims. Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Methods. Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery. Results. Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001). Conclusion. Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391

The Nottingham Hip Fracture Score (NHFS) was developed in 2007 as a predictor of 30-day mortality after hip fracture surgery following a neck of femur fracture. The National Hip Fracture Database is the standard used which calculated their own score using national data. The NHF score for 30-day mortality was calculated for 50 patients presenting with a fractured neck femur injury between January 2020 to March 2020. A score <5 was classified as low risk and >/=5 as high risk. Aim was to assess the accuracy in calculating the Nottingham Hip Fracture Score against the National Hip Fracture Database. To explore whether it should it be routinely included during initial assessment to aid clinical management?. There was an increase in the number of mortalities observed in patients who belonged to the high-risk group (>=5) compared to the low risk group. COVID-19 positive patients had worse outcomes with average 30-day mortality of 6.78 compared to the average of 6.06. GEH NHF score per month showed significant accuracy against the NHFD scores. The identification of high-risk groups from their NHF score can allow for targeted optimisations and elucidation of risk factors easily gathered at the point of hospitalisation. The NHFS is a valuable tool and useful predictor to stratify the risk of 30-day mortality and 1-year mortality after hip fracture surgery. Inclusion of the score should be considered as mandatory Trust policy for neck of femur fracture patients to aid clinical management and improve patient safety overall

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. Methods. Data from 94 hospitals on patients aged 60 to 110 who had hip fracture surgery between May 2013 and July 2013 were analysed. Data were linked to the Office for National Statistics (ONS) death register to calculate the 30-day mortality rate. Risk of death was predicted for each patient using the NHFD and Nottingham models in a development dataset using logistic regression to define the models’ coefficients. This was followed by testing the performance of these refined models in a second validation dataset. Results. The 30-day mortality rate was 5.36% in the validation dataset (n = 3861), slightly lower than the 6.40% in the development dataset (n = 4044). The NHFD and Nottingham models showed a slightly lower discrimination in the validation dataset compared with the development dataset, but both still displayed moderate discriminative power (c-statistic for NHFD = 0.71, 95% confidence interval (CI) 0.67 to 0.74; Nottingham model = 0.70, 95% CI 0.68 to 0.75). Both models defined similar ranges of predicted mortality risk (1% to 18%) in assessment of calibration. Conclusions. Both models have limitations in predicting mortality for individual patients after hip fracture surgery, but the NHFD risk adjustment model performed as well as the widely-used Nottingham prognostic tool and is therefore a reasonable alternative for risk adjustment in the United Kingdom hip fracture population. Cite this article: Bone Joint Res 2017;6:550–556

Aims. To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten’s criteria for effective assessment. Methods. A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases. Results. In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four ‘final product analysis’ (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA. Conclusion. Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre. Cite this article: Bone Joint Open 2020;1-9:594–604

The international literature base demonstrates that individuals living with diabetes mellitus (DM) are at increased risk of mortality and post-operative complications following hip fracture surgery (HFS) than non-diabetics. Studies investigating databases in American, European or Asiatic populations highlight the impact geography can have on the resultant investigation. We aim to quantify the impact DM has on HFS patients in a single university hospital. The HIPE dataset of fragility fractures occurring in Galway University Hospital from 2014–2016 were analysed and cross referenced with hospital laboratory and public databases. A database of 759 individuals was created including 515 females and 237 males, with a mean age of 78+/−12.2 years, of which 110 patients had DM. The patient length-of-stay (PLOS) was comparable in all groups with patient age being the primary influencing factor. An extended PLOS correlated with an increased long-term mortality. A trend toward increased occurrence of sub-trochanteric fractures was observed in diabetics with fewer periprosthetic and intertrochanteric fractures. Patients with DM had a significant increased risk of post-operative mortality compared to non-diabetics. Males with DM where at a greater risk of death after HFS [HR 2.29, 95% CI 1.26–4.17. p=0.006] than females with DM [HR 1.69, 95% CI 0.99–2.91. p=0.056]. The presence of DM did not directly impact a patient's PLOS or increase the need for a re-operation. DM is associated with increased post-operative patient mortality and may influence the anatomical fracture pattern. This observation will support further investigation into the mechanical and biochemical changes occurring in the femur in individuals living with DM

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

Although wait-times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Our objective was to use new population-based wait-time data to emprically derive an optimal time window in which to conduct hip fracture surgery before the risk of complications increases. We used health administrative data from Ontario, Canada to identify hip fracture patients between 2009 and 2014. The main exposure was the time from hospital arrival to surgery (in hours). The primary outcome was mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (MI, DVT, PE, and pneumonia) also within 30 days. Risk-adjusted cubic splines modeled the probability of each complication according to wait-time. The inflection point (in hours) when complications began to increase was used to define ‘early’ and ‘delayed’ surgery. To evaluate the robustness of this definition, outcomes amongst propensity-score matched early and delayed patients were compared using percent absolute risk differences (% ARDs, with 95% confidence intervals [CIs]). There were 42,230 patients who met entry criteria. Their mean age was 80.1 (±10.7) and the majority were female (70.5%). The risk of complications modeled by cubic splines consistently increased when wait-times were greater than 24 hours, irrespective of the complication considered. Compared to 13,731 propensity-score matched patients who received surgery earlier, 13,731 patients receiving surgery after 24 hours had a significantly higher risk of 30-day mortality (N=898 versus N=790, % ARD 0.79 [95% CI 0.23 to 1.35], p = .006) and the composite outcome (N=1,680 versus N=1,383, % ARD 2.16 [95% CI 1.43 to 2.89], p < .001). Overall, there were 14,174 patients (33.6%) who received surgery within 24 hours and 28,056 patients (66.4%) who received surgery after 24 hours. Increased wait-time was associated with a greater risk for 30-day mortality and other complications. The finding that a wait-time of 24 hours represents a threshold defining higher risk may inform existing hip fracture guidelines. Since two-thirds of patients did not receive surgery within this timeframe, performance improvement efforts that reduce wait-times are warranted

Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery. In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA. No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs. MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection

Currently there is an elevated public awareness of the consequences of nosocomial infection, of which, 14.5% is due to surgical site infection (SSI). Hip fracture patients are at increased risk of SSI due to their age related poor medical health, immune response impairments and decreased capacity of wound healing. Superficial SSI following hip fracture surgery can affect up to 16.9% with deep infection affecting 3.7%. Deep infection represents a major complication, from which hip fracture patients are 4.5 times less likely to survive to discharge and carries a 50% mortality at 1 year, compared to 33% without infection. Treatment requires a prolonged hospital stay, additional diagnostic testing, antibiotic therapy and surgery, resulting in the total cost of treating deep infection to be more than double that of non-infected hip fracture surgery. Wound closure aims to accurately appose the skin edges thereby promoting rapid healing and restoration of the protective dermal barrier. Failure to provide accurate skin apposition can result in delayed wound healing which has been shown to have a 3 fold risk of developing late infection. Importantly, delayed wound healing is reflected by prolonged wound ooze. We hypothesized that skin closure via sutures is better at achieving skin edge apposition than wounds closed with staples, providing more rapid wound healing. We compared staples and sutures for wound closure in hip fracture patients by using ooze duration as an outcome measure for wound healing. Duration of wound ooze was recorded in 170 patients. 65 wounds, closed with sutures, had an average duration of ooze of 1.82 days. 105 wounds, closed with staples, had an average duration of ooze of 4.97 days. This study suggests that sutures are superior to staples with regard to early wound healing in hip fracture patients

Introduction Recent changes in the management of hip fracture surgery patients may have resulted in changes in the epidemiology of venous thromboembolism (VTE). We aimed to determine the incidence of and predictive risk factors for symptomatic VTE and mortality, and the use of VTE prophylaxis, in hip fracture surgery patients. Methods Hip fracture surgery patients were enrolled in 525 hospitals in France between October 1 and November 30, 2002 in this prospective, multicenter, epidemiological study. VTE was assessed by a critical events committee at 3 months. Risk factors were identified using logistic regression. Results Data were from 6860 (97%) of 7019 enrolled patients. Median age was 82 years and 76% were women. 47% were femoral neck and 53% trochanteric or subtrochanteric fractures. All were operated on (osteosynthesis 57%, half prosthesis 35% and THR 8%). Prophylaxis with a low-molecular-weight heparin (LMWH) was administered perioperatively in 97.6% and for at least four weeks in 69.5% (median prophylaxis duration: 6 weeks). The rate of symptomatic VTE at 3 months was 1.34% (95% CI: 1.04– 1.64). There were 16 PE (rate 0.25%) and 3 were fatal. The rate of major bleeding was 1.2%. At 6 months, 1006 patients (14.7%) were dead. Significant risk factors for symptomatic VTE were: history of VTE (OR 2.9), induction of anesthesia until arrival in the recovery room > 2 hrs (OR 2.5), and varicose veins/post-thrombotic syndrome (OR 2.2). LMWH prophylaxis significantly reduced the risk of symptomatic VTE (OR 0.2). Significant predictive factors for mortality were: cancer (OR 2.3), surgical complications requiring re-intervention (OR 1.8), confusion before fracture (OR 1.8), ASA score ≥3 (OR 1.7), BMI ≤18 kg/m2 (OR 1.6), congestive heart failure (OR 1.6), atrial fibrillation (OR 1.6) and age > 80 years (OR 1.1). Conclusions Extended LMWH prophylaxis is applied widely after hip fracture surgery in France. The current rate of postoperative VTE is low. However, a major change in the care of these patients is needed because of the high mortality rate

Introduction. Delay, postponing and cancellation of hip fracture surgery leads to unnecessary starvation and adverse effects on patients and resources. Best Practice Tariffs (BPT) have been introduced to incentivise organisation into optimising the overall care for this type of injuries. Methods. Retrospective observational analysis of all consecutive cases of hip fractures over a period of 18 months; this period spanned the introduction of BPT: 10 months before and 8 months after. Data on delay, postponing and cancellation of surgery were recorded and analysed. Results. Total of 584 cases with a surgery cancellation rate of 21% (n=121). Top three reasons for cancellation: 48% medically unfit, 32 % lack of operating time, 6% patient unprepared. Rate of surgery cancellation pre-BPT 26% (n=85), post-BPT 14% (n=36). Top three reasons for cancellation pre vs. post BPT were respectively: medically unfit 48% vs. 47%, lack of operating time 32% vs. 33%, patient unprepared 6% vs. 8%. Mean time from admission to surgery was in pre-BPT: 43.03 hours, in post-BPT: 34.33 hours. Surgery occurred at ≥36 hours after admission in 43.3% (first group), in 25% (second group). Lack of operating theatre time as reason for delay in surgery dropped from 37% to 20%. In contrast, the rate of theatre list overrun increased from 7% to 16%. Conclusions. According to our district general hospital experience; the implementation of national guidelines and financial incentives helped reduce time delay and rate of cancellation of hip fracture surgery. These changes were achieved despite access to the same level of resources

The aim of this study was to investigate the risk factors, financial costs and outcomes associated with infection after hip fracture surgery. Prospective hip fracture data from the University Hospital, Nottingham, was analysed, assessing patients with either deep or superficial wound infections admitted over a five year period. 3605 patients underwent hip fracture surgery. 2.3% of these patients developed a wound infection of which 1.2% were deep wound infections. 75% of infections were due to Staphylococcus aureus and 50% of all infections were caused by methicillin-resistant Staphylococcus aureus. No statistically significant risk factors for the development of infection were identified in this study. Length of stay, cost of treatment and pre-discharge mortality were all increased with deep infection. Deep wound infection increased the average length of stay from 28 days to 100 days. This quadrupled the ward costs. The mean overall hospital cost of treating a hip fracture complicated by deep wound infection was £34903 compared to £8979 fro those who did not develop infection. Pre-discharge mortality increased from 24.2% in the control group to 30% in the infected group (p<0.006). MRSA significantly increased costs, LOS, and pre-discharge mortality compared with non-MRSA infection. These results show the huge impact that infection after hip fracture surgery has both on mortality and hospital costs

There is little evidence from the literature regarding the timing of hip fracture surgery for patients who are on the antiplatelet agent clopidogrel bisulphate (Plavix) (1). We report the results of a retrospective case control study of 40 patients comparing the timing of surgery for patients taking clopidogrel against a control group of those not taking an antiplatelet agent. Time to surgery, length of stay, transfusion requirements, wound problems and other post operative complications were examined. Within the study group of patients taking clopidogrel, we also compared those who underwent surgery within four days of stopping the clopidogrel and after four days. The transfusion requirements were greater in those patients on clopidogrel prior to admission. Wound healing and post operative complications were similar between the two groups. Total length of hospital stay and post operative length of stay were longer in the clopidogrel group. There was an increase in transfusion requirements and post operative length of stay in patients on clopidogrel undergoing early surgery (within 4 days) compared to the group where surgery was delayed. We conclude that, in this small study, transfusion requirements and length of stay were greater in patients on clopidogrel. Transfusion requirements and post operative length of stay were also greater if surgery was performed within four days of omitting clopidogrel. Further studies are required to determine optimal timing of surgery following discontinuation of clopidogrel

Hip fracture is associated with highest mortality following trauma in the elderly. The objective of this study is to evaluate the association between duration of anaesthesia and duration of surgery with 30 days mortality following hip fracture surgery. This retrospective cohort study reviewed patients underwent surgery following hip fracture in a district general hospital. Patients less than 65 years, periprosthetic and pathological fractures were excluded. Totally 254 patients were included in the study, who had surgery between February 2005 and September 2008 (20 months period). Mortality details retrieved through National Statistics database. Chi Square tests and Logistic regression analyses were performed to check the relationship between 30 days mortality and all independent variables including duration of anaesthesia and duration of surgery. The incidence of 30 days mortality following hip fracture surgery was 9.4%. The commonest reason of death was cardiac failure and chest infection. Patients who had General anesthesia (GA) had more complications and mortality in comparison with those who had regional anaesthesia. GA increases the odds of 30 days mortality to 2.5 times. Patients under American Society of Anesthesiologists (ASA) II had decreased odds of 30 days mortality than ASA III & IV (odds Ratio 0.16). However duration of anesthesia up to 120 minutes and duration of surgery up to 90 minutes were not associated with 30 days mortality (P>0.05). The 30 days mortality following dynamic hip screw fixation surgery was 14.6% and intra medullary nail was 12.5%. The 30 days mortality in cemented hemi-arthroplasty was 6.9% and uncemented hemi-arthroplasty was 6%. The 30 days mortality was nil in the group of patients who had undergone cannulated hip screw fixation. In elderly people following hip fracture surgery 30 days mortality was not affected by duration of anaesthesia and duration of surgery. However 30 days mortality was related with GA, ASA III & IV and post-operative complications mainly cardiac failure and chest infection. These patients need specialist medical care

There is still much debate on the appropriateness of taking post operative radiographs especially in the presence of high quality radiography that image intensifiers now provide. The aim of this study was to determine current UK practice regarding the use of check radiographs and to compare this practice with the implant related complications. A postal performa was sent to 450 randomly chosen UK Trauma and Orthopaedic Consultants to assess their practice regarding check radiographs following hip fracture surgery. In addition a case note review of all patients undergoing hip fracture surgery over the three years of 2001 to 2003 at Selly Oak Hospital, was performed. Patients undergoing revision surgery in the same admission were identified. The decision to revise was noted to determine whether check radiograph influenced the decision. Response rate to the performa was 66.7% (300/450). 96% routinely took postoperative radiographs following Hemiarthroplasty. Of these, 87% allowed the patient to mobilise before checking the radiograph. In the DHS group, 61% took check radiographs. Of these, 75% allowed the patient to mobilise prior to reviewing the radiograph. Following Cannulated screw fixation, 58% routinely performed check radiographs and 67% allowed the patient to mobilise before reviewing the radiograph. 1265 hip fracture surgeries were performed in our unit in three years. Only one decision to revise was based on a problem identified on a routine check radiograph. We highlight the lack of national consensus on the use of post operative radiographs. We recommend the use of post operative radiographs only when clinically indicated, hence sparing the patient from discomfort, unnecessary exposure to radiation as well as allowing more effective utilisation of radiological and human resources

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Aims

Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures.

There is currently limited information available on the benefits and risks of extended thromboprophylaxis after hip fracture surgery. SAVE-HIP3 was a randomised, double-blind study conducted to evaluate the efficacy and safety of extended thromboprophylaxis with the ultra-low molecular-weight heparin semuloparin compared with placebo in patients undergoing hip fracture surgery. After a seven- to ten-day open-label run-in phase with semuloparin (20 mg once daily subcutaneously, initiated post-operatively), patients were randomised to once-daily semuloparin (20 mg subcutaneously) or placebo for 19 to 23 additional days. The primary efficacy endpoint was a composite of any venous thromboembolism (VTE; any deep-vein thrombosis and non-fatal pulmonary embolism) or all-cause death until day 24 of the double-blind period. Safety parameters included major and clinically relevant non-major bleeding, laboratory data, and treatment-emergent adverse events (TEAEs). Extended thromboprophylaxis with semuloparin demonstrated a relative risk reduction of 79% in the rate of any VTE or all-cause death compared with placebo (3.9% vs 18.6%, respectively; odds ratio 0.18 (95% confidence interval 0.07 to 0.45), p < 0.001). Two patients in the semuloparin group and none in the placebo group experienced clinically relevant bleeding. TEAE rates were similar in both groups. In conclusion, the SAVE-HIP3 study results demonstrate that patients undergoing hip fracture surgery benefit from extended thromboprophylaxis. Cite this article: Bone Joint J 2013;95-B:459–66

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: In orthopedic surgery, the optimal duration of thromboprophylaxis is debated, and very few data are available in hip fracture. We addressed these issues in 5 randomized double-blind clinical trials of fondaparinux. Methods: In four studies in 7344 orthopedic surgery patients, fondaparinux was administered up to 11 days and compared to approved enoxaparin regimens. In the PENTHIFRA-Plus study in 656 hip fracture surgery patients, after an initial treatment with fondaparinux for 7±1 days, patients were randomized to fondaparinux or placebo for additional 21±2 days. In all trials, primary efficacy was venous thromboembolism (VTE), at the end of the treatment period. Results: In the four 11-day prophylaxis studies, fondaparinux reduced the incidence of VTE from 13.7% with enoxaparin to 6.8% (risk reduction [RR]: 55.2%; P< 0.001). Fondaparinux efficacy was significantly influenced by treatment duration (P< 0.001): for instance, the incidence of VTE was lower in patients treated for 9 to11 days (5.2%) than in patients treated for ≤5 days (8.7%, P= 0.038). In the PENTHIFRA-Plus study, the incidence of VTE up to 4 weeks was reduced to 1.4% compared with 35.0% with placebo (relative RR: 95.9%, P< 0.001). The incidence of symptomatic VTE was also significantly lower with fondaparinux (0.3%) than with placebo (2.7%, relative RR: 88.8%, P=0.021). Conclusions: Fondaparinux efficacy in preventing VTE in orthopedic surgery increased significantly with a longer duration of treatment. Hip fracture surgery patients are at high risk of VTE up to 4 weeks after surgery and treatment with fondaparinux for 4 weeks postoperatively provides greater benefit than active treatment for only 1 week

Purpose. Hip fractures are the most common injury requiring hospitalization in both men and women over the age of 65. There is significant mortality associated with hip fracture and delay to surgical treatment increases this rate. We undertook an ethnographic study exploring organizational barriers to timely hip fracture surgery. Method. Using purposive sampling, over 30 interviews were conducted at a large teaching hospital with various professionals involved in the process of getting a patient from ED to surgery and to surgical discharge. This included anaesthetists, surgeons, emergency and internal medicine physicians, nurses, social workers and senior administrative personnel. An additional twelve patient interviews were conducted and reported separately. Following transcription of each tape, a small study team met over the course of several months to read and discuss each transcript in detail. A coding template was developed and each transcript coded with emerging themes noted. Results. Several important themes emerged which impact time to hip fracture surgery. We have classified these as: 1) issues related to inter and intra-professional collaboration; 2) social admissions or “failure to cope” (FTC) patients who are referred to surgical orthopaedic ward beds; 3) difficulties in discharge to rehabilitation; and 4) the disconnect between hospital administration's discourse of efficiency while insufficient resources choke optimal patient flow of care. Conclusion. Inter and intra-professional collaboration has been recognized as central to the provision of excellent, patient-centred care yet not often been studied empirically. Our study revealed obstacles at several stages that stretched from admission at the ED to post-surgical discharge. Tensions were reported between medical, anaesthetic and surgical specialists in relation to consults, anticoagulation and pre-op testing that frustrated attempts to operate within the current Ontario wait time standard of 48 hours. Competition for scarce hospital beds also increased this tension and sense of frustration. In addition, non-operative fracture patients are often referred from ED to orthopaedic surgical wards, thus further delaying access for patients requiring emergent hip fracture surgery due to lack of surgical bed availability. On the basis of these findings our team hopes to advance recommendations designed to address these issues and improve wait times that will be applicable to other hospitals. These recommendations may include the inclusion of a geriatrician or hospitalist on orthopaedic wards as well as harmonized guidelines and care pathways. In addition, we are adding to the understanding of the social organization of acute care in complex and demanding environments

Introduction: Rehabilitation of hip fracture patients is often lengthy with bed day consumption accounting for up to 85 % of the total hospitalization cost. Data suggests that patients who suffer surgical complications requiring re-operation have an excessive length of hospitalization, but the overall impact of surgical complications including those not requiring re-operations have not been examined in detail. Methods: Six hundred consecutive, unselected patients with a primary hip fracture were included between 2002 and 2004. All patients received surgery and a multimodal rehabilitation program. Surgical complications were stratified into those requiring re-operation (< six months) and those not allowed mobilization postoperatively due to instability of the fracture. Surgical complications were audited and classified as being due to a patient fall, infection or due to a suboptimal surgical procedure, specified as suboptimal operation method, fracture reduction or implant position. Results: 19.3 % (116/600) of the admitted patients were re-operated or immobilized. Assuming that the patients with complications otherwise would have had the same length of stay as the remaining patients, 27.2 % (3814/14038) of total bed day consumption was due to surgical complications. The audit of complications showed that 64 complications (55 %) were due to a suboptimal primary surgical procedure, 18 (16 %) to infections, 6 (5 %) to falls and 28 (24 %) could not be ascribed to an apparent course. Conclusions: Surgical complications secondary to primary hip fracture surgery accounts for 27.2 % of the total bed consumption if secondary admissions due to re-operations are taken into account. Our audit suggests that as much as half the complications potentially could be spared through optimization of surgical procedures

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery. Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred. There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

Background. Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery. Method. Prospective analysis of 150 patients who had operative fixation of neck of femur fractures in a district general hospital. Patients were asked on the third post-operative day to select which procedure they had undergone from a diagram of four different neck of femur surgeries (cannulated screws, cephalomedullary nail, dynamic hip screw and hemiarthroplasty). Exclusion criteria for patient selection - mini mental score of < 20 and confusion secondary to delirium. Results. All patients had signed consent form 1 which was matched to the procedure. All patients were consented by an FP2, CT1 or other SHO. The mean age of patients was 83years. 5% had cannulated screw fixation, 45% had a hemiarthroplasty, 42% had a dynamic hip screw and 8% had a cephalomedullary nail. 47% of patients could correctly identify the procedure they had undergone on the 3. rd. post-operative day. Conclusions. This study shows that there are questions about the effectiveness of informed consent and patient understanding of the procedure before and after hip fracture surgery. We suggest that further detailed studies may highlight the need for alternative ways of communicating procedures to the patients or that more specialised training is required for those explaining hip fracture surgery to patients. Improvements in these areas might help ensure the true informed consent required

Aims. Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery. Methods. This observational cohort study enrolled consecutively admitted patients with a proximal femoral fracture, for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. A total of 1,803 patients were included, of whom 1,428 had surgery < 24 hours and 375 had surgery ≥ 24 hours after admission. Results. Prolonged total length of stay was found when surgery was performed ≥ 24 hours (median 6 days (interquartile range (IQR) 4 to 9) vs 7 days (IQR 5 to 10); p = 0.001) after admission. No differences in postoperative length of hospital stay nor in 30-day mortality rates were found. In subgroup analysis for time frames of 12 hours each, pressure sores and urinary tract infections were diagnosed more frequently when time to surgery increased. Conclusion. Longer time to surgery due to non-medical reasons was associated with a higher incidence of postoperative pressure sores and urinary tract infections when time to surgery was more than 48 hours after admission. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay. Cite this article: Bone Joint J 2022;104-B(12):1369–1378

Background and Objective. Patients undergoing hip fracture surgery have a high peri-operative mortality rate. We performed a retrospective study to ascertain if there is any relation between postoperative haemoglobin (Hb) decrease and cardiac related events following the surgery. Methodology. We carried out a retrospective study in this University Hospital's trauma unit. All patients operated for fracture neck of femur (hemiarthroplasty and DHS – Dynamic Hip Screw) between July 2006 and August 2008 were included in the study. Electronic records from the trauma unit, pathology portal, operating theatre and blood bank were obtained to identify the pre-operative and post-operative Hb levels, amount of blood transfused and Troponin T (TnT) level. Results. A total of 632 patients were operated for fracture neck of femur surgery during the study period of which 616 had complete perioperative blood results (DHS: 341; 80 male and 261 females and Hemiarthroplasty: 275; 68 male and 207 females). 60 patients had TnT levels performed within 10 days of the operation, thus suggesting possible cardiac related symptoms. Of these, 25 patients had a raised TnT (= 0.03). 24 (96%) of these patients had a post-operative Hb decrease compared with 550/591 (93%) patients without TnT (mean 2.3, range 0.1-5.6 g/dl compared with a mean of 2.4 and a range of 0-7 g/dl). Scatter diagram illustrated a positive correlation between post-operative Hb drop and TnT rise. Linear regression analysis concluded that a post-operative Hb drop is significantly correlated to TnT rise at the 10% level (p = 0.064). Conclusions. Post-operative Hb decline correlates with a raised TnT. As a standard protocol, post-operative bloods including Hb are performed the day after surgery. Given the correlation demonstrated, we recommend Hb levels to be analysed on day of surgery, to effectively manage low Hb levels before cardiac symptoms can develop

The December 2023 Hip & Pelvis Roundup. 360. looks at: Early hip fracture surgery is safe for patients on direct oral anticoagulants; Time to return to work by occupational class after total hip or knee arthroplasty; Is there a consensus on air travel following hip and knee arthroplasty?; Predicting whether patients will achieve minimal clinically important differences following hip or knee arthroplasty; High-dose dual-antibiotic-loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomized controlled trial; Vitamin E – a positive thing in your poly?; Hydroxapatite-coated femoral stems: is there a difference in fixation?

Introduction. Reoperation within thirty days after hip fracture surgery is associated with increased mortality, length of stay and cost of care. The United Kingdom National Hip Fracture Database (NHFD) reported a significant increase in the 30-day reoperation rate for patients undergoing surgery for hip fractures in our unit from 2012 to 2014. We audited our data in order to validate this and identify any reversible trends. Methods. Between January 2012 and December 2014, 1757 consecutive procedures for hip fracture were performed in our unit. Patients who had a reoperation within 30 days and those recorded as ‘unknown’ under the reoperation category were identified. Patients with hip dislocations were included. Patient demographics, diagnosis, treatment and outcomes were recorded. This was compared with reoperation for all causes after 30 days over a 12-month period. Results. Nineteen patients (1.1%) underwent a reoperation within 30-days. There was no significant change in the annual incidence over the period studied. Infection was the leading cause for reoperation (47%). The NHFD also reported a 10-fold increase in the incidence of periprosthetic fractures during the study period (0.18% to 1.78%). This did not correlate with our findings (0% to 0.36%). Our NHFD data entry system was unchanged over the 3-year period. We identified a change in NHFD data entry form in April 2014 which corresponded to the increase in the incidence of periprosthetic fractures and overall reoperation rates. Discussion. These results suggest there is a need for local validation of NHFD data. The current design may contribute to imprecise data recording. We suggest the introduction of an automatic notification system informing the local NHFD lead of any reoperation within 30 days would assist in real-time monitoring. This study led us to identify infection as the leading cause of reoperation at our institution and initiate improvement measures

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic, and long bone fractures; interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews; and pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

Aim: Rehospitalisation following surgery is widely regarded as an important outcome measure. In this study we identified causes of readmission following surgery, in proximal hip fracture patients.

Method: A total of 267 patients underwent surgery for proximal hip fractures in one year (2001–2002) at our institution. Notes of these patients were reviewed to look for readmissions within three months.

Results: A total of 43 (16.1%) patients died during initial hospital admission episode. Of the remaining 224 patients, 46 (20.5%) patients had an emergency unplanned readmission back to the hospital, within 3 months of discharge. 9 admissions (19.5% of readmissions, 4.01% of discharged patients) were due to operative site complications. 8 patients (17.3% of readmissions, 3.5% of discharged patients) were referred back for suspected thromboembolic events. 29 admissions (63.04% of readmissions, 12.9% of discharged patients) were due to other medical problems. Of these 18 medical problems could be attributed to preceding hip fracture. 15 patients died during this 2nd admission episode. 10 of these patients could have their ‘cause of death’ attributable to previous hip fracture, though this was not mentioned in their death certificates. A total of 8 patients had died in community in the 3 months following discharge giving a total mortality of 24.7% (66/267 patients) within 3 months.

Conclusions: Hip fracture is underreported as a cause of prolonged morbidity and mortality. A high percentage of these patients were readmitted adding to resource crunch. An understanding of the causes of readmission would help to decrease this workload.

Prospective data on 6905 consecutive hip fracture patients at a district general hospital were analysed to identify the risk factors for the development of deep infection post-operatively. The main outcome measure was infection beneath the fascia lata.

A total of 50 patients (0.7%) had deep infection. Operations by consultants or a specialist hip fracture surgeon had half the rate of deep infection compared with junior grades (p = 0.01). Increased duration of anaesthesia was significantly associated with deep infection (p = 0.01). The method of fracture fixation was also significant. Intracapsular fractures treated with a hemiarthroplasty had seven times the rate of deep infection compared with those treated by internal fixation (p = 0.001). Extracapsular fractures treated with an extramedullary device had a deep infection rate of 0.78% compared with 0% for those treated with intramedullary devices (p = 0.02).

The management of hip fracture patients by a specialist hip fracture surgeon using appropriate fixation could significantly reduce the rate of deep infection and associated morbidity, along with extended hospitalisation and associated costs.

Our audit examined the rates of complication in the surgical wounds of patients having surgery for fractured neck of femur, comparing the use of skin clips and an absorbable subcuticular suture.

The initial part of the audit compared the commonly used methods of skin closure at our institution, as outlined above. One hundred consecutive patients with fractured necks of femur (NOF) were studied. The closure of the wounds was randomly allocated between skin clips and subcuticular suture. The wounds were monitored for signs of complications, including infection, for the duration of hospital stay. It was found that the use of skin clips carried with it a significantly higher rate of complication (11.1% ) when compared with use of subcuticular absorbable suture (0% ). At this stage, we concluded that the latter method be adopted as departmental policy.

A further study was performed one year later to reevaluate the efficacy of the new practice. A further fifty consecutive patients with NOF were studied using the same parameters as before. Our results demonstrated that the rate of complication was clinically and statistically significant.

We closed the loop of the audit cycle and concluded that the use of an absorbable subcuticular suture should be the preferred method of closure of hip wounds in NOF surgery.

Aims. The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. Methods. The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, “all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living”. Results. A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). Conclusion. Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972–979

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. Methods. This was a retrospective analysis of publicly available audit data obtained from the National Hip Fracture Database (NHFD) 2018 benchmark summary and Facilities Survey. Data extraction was performed using a dedicated proforma to identify relevant hospital-level care process and outcome variables for inclusion. The primary outcome measure was adjusted 30-day mortality rate. A random forest-based multivariate imputation by chained equation (MICE) algorithm was used for missing value imputation. Univariable analysis for each hospital level factor was performed using a combination of Tobit regression, Siegal non-parametric linear regression, and Mann-Whitney U test analyses, dependent on the data type. In all analyses, a p-value < 0.05 denoted statistical significance. Results. Analyses included 176 hospitals, with a median of 366 hip fracture cases per year (interquartile range (IQR) 280 to 457). Aggregated data from 66,578 patients were included. The only identified hospital-level variable associated with the primary outcome of 30-day mortality was hip fracture trial involvement (no trial involvement: median 6.3%; trial involvement: median 5.7%; p = 0.039). Significant key associations were also identified between prompt surgery and presence of dedicated hip fracture sessions; reduced acute length of stay and both a higher number of hip fracture cases per year and more dedicated hip fracture operating lists; Best Practice Tariff attainment and greater number of hip fracture cases per year, more dedicated hip fracture operating lists, presence of a dedicated hip fracture ward, and hip fracture trial involvement. Conclusion. Exploratory analyses have identified that improved outcomes in hip fracture may be associated with hospital-level service characteristics, such as hip fracture research trial involvement, larger hip fracture volumes, and the use of theatre lists dedicated to hip fracture surgery. Further research using patient level data is warranted to corroborate these findings. Cite this article: Bone Joint J 2021;103-B(10):1627–1632

Aim

This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture.

Introduction: It is well documented that surgery following hip fractures (#NOF) has accepted failure rates of between four and 33%. An average of 120 patients are admitted to Wellington hospital for #NOF each year. Aim: We aimed to identify the rate of and reasons for readmission for further surgery within a year of #NOF in patients admitted to Wellington hospital. Methods: A list of all patients admitted for surgical treatment of hip fractures during 1998 and 1999 was obtained from the hospital database. Demographic data, type of fracture, surgical intervention, readmission for surgery on the same hip and subsequent surgical intervention for each patient were noted. Results: Of the 209 patients who underwent surgery for 215 fractures, 55% (n=119) sustained subcapital, 43% (n=92) intertrochanteric and 2% (n=4) other fractures. Seven percent (n=15) were readmitted for a second hip operation within twelve months. Eighty percent (n=12) of those who were readmitted had sustained sub-capital fractures. Of those in the readmission group primary surgery comprised ORIF with cannulated screws (40%), compression screw with or without one cannulated screw and plate (40%), hemiarthroplasty (HA) (13%) and total hip arthroplasty (THA) (7%). For patients who had sustained a subcapital fracture (n=117), 21% (P< 0.05) of those who had been treated with cannulated screws required further surgery compared with 2–14% who had the other types of surgery. Conclusions: Rates of readmission for further hip surgery following hip fracture in Wellington hospital appear to be in the lower range of those reported elsewhere

Introduction

We implemented an exhaustive operative and supervision algorithm for surgical treatment of hip fractures primarily based on own previously published literature. The purpose was to improve supervision and reduce the rate of reoperations.

Although it has long been appreciated that a healthy balanced diet improves health, there is a growing understanding of the way in which certain nutrients can actually improve immune function. Boosting immune function by the use of “immunonutrition” has been shown to improve outcomes, in particular rates of infective complications, in certain groups of surgical patients. In this study we examine the immune status of elderly patients who have suffered a hip fracture and are known to be vulnerable to infection and poor post-operative outcomes to identify specific immune defects associated with this particular cohort. This may allow us to explore the potential benefits of immunonutrition in this group of patients in the future. This was a cohort observational study, in which a series of 16 patients who underwent surgery for hip fractures were followed. The patients were female patients with an age of 60 to 85 years and a mental status questionnaire score of at least 8 out of 10. Immune function was evaluated prior to surgery, on the day following surgery and then at between days 4 and 7 post-operatively. Samples were tested directly ex-vivo using a variety of flow cytometric assays. We report profound loss of innate immune function related specifically to monocyte and granulocyte ability to generate a respiratory burst in response to E.coli uptake persisting up to day 7 post-operatively. In addition, serum cytokine levels indicated very poor T cell function, in identifying these patients as particularly vulnerable to infections

A prospective study of 142 consecutive patients admitted with fracture of the neck of femur was performed. 42 patients were operated within 24 hours of time of fracture (group 1), 46 within 24 to 48 hours (group 2) and 47 more than 48 hours later (group 3). Three patients were treated conservatively and in four patients the exact time of fracture was not known.

The reason for delay of the operation was lack of theatre space in the majority of cases (64 patients). Medical problems accounted for delay in only 10 patients.Seven patients out of 42 in group 1 died within four month (16.7%), compared to 11 of 46 in group 2 (23.9%), and 6 out of 47 in group 3 (12.8%). This difference was not statistically significant.

There was no significant difference in requirement for pre- and postoperative blood transfusion between the three groups. No patient operated within 24 hours developed pressure sores. Three patients in group 2, and six patients in group 3 developed pressure sores. Chest infections occurred in three patients in group 2, and in three patients in group 3. None of the patients operated on within 24 hours developed a chest infection, wound infection or urinary tract infection. Two patients who had a Girdlestone procedure for deep infection were operated more than 48 hours after the fracture. One patient requiring drainage for wound infection had the operation 47 hours after the fracture.There were no superficial or deep wound infections, pressure sores, or chest infections if operated on within 24 hours of fracture. There was no difference in the requirement for blood transfusion. Patients operated within 24 to 48 hours of fracture had the highest mortality, although this was not statistically significant.

Background and Purpose: If hip fracture patients are to return directly to their own home in the community, instead of transfer to a secondary rehabilitation unit or nursing home, the regain of independency in basic mobility is necessary. Therefore a method for an early, quick and valid prediction of short-term rehabilitation outcome is important for ward personnel to adjust and plan expectations and rehabilitation needs for each patient. This study validates the New Mobility Score(1) as a predictor of the postoperative day of independency in basic mobility, functional mobility at discharge and discharge status.

Subjects: Six hundred and one consecutive unselected hip fracture patients admitted to a special hip fracture unit in an orthopaedic ward.

Methods: The New Mobility Score that describes the prefracture functional level was recorded on admission, while functional mobility was evaluated by the Timed ‘Up & Go’ Test. All patients followed a well defined multi-modal fast track rehabilitation program including intensive physiotherapy. The New Mobility Score is a composite score of the patient’s ability to perform: indoor walking, outdoor walking and shopping before the hip fracture, providing a score between zero and three (0: not at all, 1: with help from another person, 2: with an aid, 3: no difficulty) for each function, resulting in a total score from 0 to 9, with nine indicating a high prefracture functional level. The correlations of the New Mobility Score to all outcome parameters and between groups were examined and for those that significantly predicted the individual outcome, the predictive value and likelihood ratios with 95% CI were calculated. Correlations were measured by the Spearman’s rho with a level of significance of 0.05.

Results: The New Mobility Score was assessed on all 601 patients, but only those 436 (73%) admitted from own home were included in analyses. The New Mobility Score was a significant predictor (P< 0.001) for postoperative day of independency in basic mobility (rho=0.422), Timed ‘Up & Go’ Test performances (−0.301) and length of stay (−0.438). A cutoff point of 7 gave the highest negative predictive value (0.95 and 0.91*) and sensitivity (0.91) of the New Mobility Score to patients not achieving independency in basic mobility and to patients not being discharged directly to own home* with a negative likelihood ratio of 0.2.

Discusssion and conclusion: The results suggest that the New Mobility Score is a valid and easily applicable score that provides the ward personal with a predictive value of the short-term potential of independency in functional mobility during admission and discharge status.

Introduction: We derived an exhaustive operative and supervision guideline for the treatment of hip fractures from the current international and own published literature, and implemented the guidelines in our department.

Methods: 1274 unselected consecutive patients admitted with a hip fracture were included, 336 of these prospectively after implementation of the new guideline. Demographic parameters, hospital treatment and re-operations were assessed from patient journals. Re-operations were recorded after six months.

Results: 95% (320/336) of operative procedures were found to have followed the new guideline treatment compared to 78% (733/938) prior to its introduction (p< 0.001 X2). Retrospectively we found that only 12% (121/1053) of operative procedures performed as the new guideline prescribes were re-operated compared to 24% (53/221) of operative procedures performed with other methods (p< 0.001 X2). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score, time from admission to operation and level of surgeon’s experience, not following the guideline was the only significant predictor for re-operation (p< 0.001 log. reg.)

After implementing the guideline, the rate of unsupervised junior registrars performing operations declined from 20% (188/938) to 6% (21/336, p< 0.001 X2). The rate of reoperations declined from 15% (139/938) to 10% (35/336, p=0.044 X2, p=0.043 log.reg.), with a 20% (85/436) to 13% (23/174) decline for intracapsulary and an 11% (54/502) to 7% (12/162) decline for extracapsulary fractures.

Conclusion: An exhaustive operative guideline for hip fracture treatment can be implemented. In our case, the guideline both raised the rate of supervision and reduced the rate of reoperations.

BACKGROUND AND PURPOSE: Previous studies using the Timed Up & Go (TUG) as a predictor of falls have primarily been based on retrospective data, while no prospective studies using the TUG to predict falls in hip fracture patients are available. The purpose of this study was to determine if the TUG could predict falls in hip fracture patients during six months follow up.

SUBJECTS: Seventy nine elderly consecutive unselected hip fracture patients being able to perform the TUG when discharged directly to their own home or assisted living facilities from a special acute orthopedic hip fracture unit, with 59 (75 %) being able to participate in the follow-up interview.

METHODS: In a prospective study all patients were contacted for a six months follow up interview about falls since discharge from the hospital and the TUG performed at discharge was compared with the New Mobility Score describing functional level before fracture, mental status on admission, gender, fracture type, residence and walking aids before and after fracture. All patients followed a well-defined care plan with multimodal fast track rehabilitation including an intensive physiotherapy program comprising two daily sessions and discharge was according to standardized criteria. Analyses and correlations of all variables were examined for prediction of falls and sensitivity, specificity, predictive values and likelihood ratios were calculated. Falls were classified as none vs. one or more.

RESULTS: Among the 59 patients in the follow up group, 19 patients (32 %) had experienced one ore more falls in the period since discharge, four of which resulted in new hip fractures. The TUG at discharge using a cutoff point of 24 seconds was the only parameter that significantly (P =.01) predicted falls within six months follow up, resulting in a sensitivity of 95%, a negative predictive value of 93%, and a negative likelihood ratio of 0.1.

DISCUSSION and CONCLUSION: The results suggest that the TUG is a sensitive measure for identifying hip fracture patients in risk of new falls, and it should be part of future outcome measures to decide in whom falls preventative measures should be instigated.

Introduction: We present the use of Orthopaedic POSSUM Score and Surgical Risk Score (SRS) in femoral neck fracture surgery. The objective of this study was to identify the physiological status at admission and at operation and identify differences in predictive and actual patient operative outcomes.

Material and Methods: All 338 consecutive, hip fractures from December to July 2005 at three hospitals were assessed prospectively. Collection of demographic, admission, and operative POSSUM, and SRS scores, fracture pathology, physiological status, and outcomes were analyzed.

Results: In total, 306 (90.5%) patients had surgery. The median age was 73 years (range 55–95). The majority had co-morbidities (77.5%; n=237), as suggested by average ASA scores of 3.2. POSSUM predicted mortality was 13.6% (n=25) at 30 days, whereas the SRS predicted 11.4% (n=21), but mortality was 7.1% (n=13) if operated before 48 hours. Differences between admission and operative physiological Possum score increased with operative delay. Physiological scores over 30 had a 67.8% risk of 30-day mortality. Eighty-six patients had an increase in physiological score from admission to operation, resulting in higher analgesic requirements and reduced mobility scores (P< 0.005).

Discussion: Possum and SRS had a tendency to predict prior than actual operative mortality. Nevertheless, comparison of admission and operative physiological POSSUM scores indicate room for improvement in pre-operative care if surgery is delayed.

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

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

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Solid organ transplant (SOT) recipients present an increased medical risk; however, few studies analyze the outcomes of these patients undergoing hip fracture surgery. This study aimes to determine the incidence of hip fracture in SOT patients and to compare the outcomes of SOT patients with matched non-SOT controls after hip fracture fixation. A retrospective review identified 20 SOT patients with hip fracture at a single center from 2016 to 2021 and were matched (1:1) with a cohort of 20 patients with hip fracture without SOT. Patient outcomes, mortality/survival and clinical outcomes were compared between two groups. The incidence of hip fracture in SOT patients was 20/1787, 1.1%. There were significant differences in mortality rate (73.3% SOT group vs. 26.7% non-SOT group; p<0.05). There were no differences in survival time (p=0.746). There were no differences in time to surgery (5.0 days SOT group vs. 3.1 days non-SOT group; p=0.109), however, there were significant differences in the hospital length of stay (14 days SOT group vs. 8.6 days non-SOT group; p=0.018). There were no differences regarding the complication rate between the two groups (9/20, 45% vs. 6/20, 30% in the SOT and non-SOT groups, respectively). SOT patients with associated hip fracture required longer hospital length of stay than non-SOT patients. SOT patients did not show greater clinical complications; however, they presented higher mortality rate compared to non-SOT patients

Aims. During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. Methods. This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Results. COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. Conclusion. Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136–1145

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

The National Hip Fracture Database (NHFD) started collecting data on peri-prosthetic femoral fractures (PPFF) in December 2019. We reviewed the data from the first year of data collection to describe the patients being admitted with PPFF and the care they received according to established Key Performance Indicators (KPIs) used in hip fracture surgery. We performed a retrospective review of the NHFD between 1 January and 31 December 2020. Analyses consisted of the summary statistics used to generate the NHFD annual report. Of the KPIs used in hip fracture, data were available for PPFF on time to assessment by a geriatrician (KPI 1), time to theatre (if applicable) (KPI 2), and mobilisation the day after surgery (if applicable) (KPI 4). There were 2,411 PPFF fractures around a hip or knee replacement reported out of a total of 2,606 PPFF. Of the 171 hospitals reporting data to the NHFD, 135 reported at least one. The median number of fractures per hospital was 14 (IQR 8, 25, range 1 to 110). The median age of patients was 84 (range 60 to 104) and 1,604 (67%) patients were female. Of the 1,850 occasions a time to geriatrician review was documented, review within 72 hours was achieved on 89.2% of occasions. Of the 1,973 patients who underwent operative interventions, 546 patients went to theatre before the 36-hour target (28.4%). Of patients who had surgery 1,323 (67.4%) were mobilised the following day. In the first year collecting data on PPFF we can give the first idea of the incidence of these life changing injuries. Whilst geriatrician review with 72 hours was achieved in a high proportion of cases nationally, our data suggest fewer patients are mobilised the day after surgery. Notably, only 28.4% of patients who were managed operatively went to theatre within 36 hours of admission. We provide the first insight into the incidence and management of these injuries

This study aims to investigate that a single dose of tranexamic acid (TXA) will reduce blood loss and transfusion rates in elderly patients, undergoing intertrochanteric (IT) or femoral neck fractures surgery. Consecutive elderly patients receiving hip fracture surgery for stable or unstable IT fracture, treated with short intramedullary nail (IMN) insertion as well as cemented hemiarthroplasty for acute femoral neck (subcapital) hip fracture, were screened for inclusion in this single-centre randomized trial. Patients were randomly allocated to a study group by sealed envelope. One TXA dose of 15 mg/kg i.v. diluted in 100 ml N/S or one placebo dose i.v. in 100 ml N/S were administered 5 mins before the skin cut. Haemoglobin (Hb) concentration was measured at admission time and prior to surgery. Post-operatively it was measured on a daily basis until day 4, giving a total of four Hb measurements (days 1 to 4). The transfusion trigger point was determined in accordance with the French guidelines for erythrocyte blood transfusion. The transfusion trigger was 10 g/dl for patients at risk, while in all other cases, it was 9 g/dl. Information regarding the transfusions number was assessed directly by the hospital blood bank database. Blood loss was calculated by the Hb dilution method. Nadler's formula was used to calculate patients' blood volume. For calculation of total blood loss (TBL) expressed to total Hb loss and total Volume loss, the number of transfusions (55 grams of Hb per transfusion), the Hb concentration on preoperatively (Hgbi) and the Hb concentration on the last measure (Hgbe) were used. (Hb balance method). The primary efficacy outcome was the number of transfusions of allogeneic RBC from surgery up to day 4. The secondary ones were the total blood loss from surgery to day 4 as it was calculated by Hb-balance method. After randomization, 35 patients with femoral neck fracture and 30 patients with IT fracture received TXA prior to surgery. Respectively, 30 patients with femoral neck fracture and 55 with IT fracture didn't receive TXA. The groups did not differ significantly in their basic demographics (age, gender, BMI, injury mechanism, ASA score, co-morbidities). Results showed that patients undergoing hemiarthroplasty after receiving TXA, were transfused with less allogeneic RBC and had less total blood loss than patients that didn't receive TXA, but without statistical significance. While patients treated with IMN in the TXA group received a significantly lower number of RBC units than the control group (1.28 ± 1.049 vs 2.075 ± 1.685), (P = 0.0396), had a significantly lower loss of Hb (98.59 ± 55.24 vs 161.6 ± 141.7), (P = 0.0195) and a lower total blood volume loss (951.3 ± 598.9 ml vs 1513 ± 1247 ml), (P = 0.023). This trial confirmed TXA administration efficacy in reducing blood loss and transfusion rate in elderly patients undergoing hip fracture surgery. A TXA single dose may be a safer option, taking into account these patients' physiological status and co-morbidities

Aims. To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). Methods. A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)’s Perioperative Special Interest Group and clinicians’ personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. Results. A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. Conclusion. This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people. Cite this article: Bone Jt Open 2023;4(10):766–775

Background of study. There has been an exponential increase in the use of direct thrombin (DT) and factor Xa inhibitors (FXI) in patients with cardiovascular problems. Premature cessation of DT/FXI in patients with cardiac conditions can increase the risk of coronary events. Our aim was to ascertain whether it is necessary to stop DT and FXI preoperatively to avoid postoperative complications following hip fracture surgery. Materials and Methods. Prospective data was collected from 189 patients with ongoing DT/FXI therapy and patients not on DT/FXI who underwent hip fracture surgery. Statistical comparison on pre- and postoperative haemoglobin (Hb), ASA grades, comorbidities, operative times, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rates between the two groups was undertaken. Results. There were 91 patients in the DT/FXI group (DTX) and 88 in the non-DTX group (NDTX). Mean age was 81.9 years. There was no difference in ASA grade, number of comorbidities (except cardiac comorbidities), age, gender and operation times between the groups. Mean preoperative Hb was 12.9 g/dl and 13.5 g/dl respectively in the DTX and NDTX. 4 and 2 patients respectively required transfusions postoperatively in the DTX and NDTX (p= 0.17). We found no difference with respect to LOS, wound infection, haematoma and reoperation rates between the two groups postoperatively. Conclusions. Our study suggests that maintaining DT and FXI therapy throughout the perioperative period in high risk patients with femoral neck fractures is not associated with an increased risk of bleeding or complications following hip fracture surgery

Aims. Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. Methods. This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. Results. Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75. th. percentile) proportion of recent surgical admission compared to a low (25. th. percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). Conclusion. A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264–270

Aims. Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery. Patients and Methods. All consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery. Results. We included 829 patients; the mean age was 81 years (. sd. 11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01). Conclusion. Our results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into account in perioperative management. Cite this article: Bone Joint J 2019;101-B:1122–1128

Aims. The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years. Methods. This was a population-based cohort study on hip fracture patients using prospectively gathered data from several national registries in Denmark from 2004 to 2015 with up to five years follow-up. The primary outcome was mortality and the secondary outcome was reoperation. Hazard ratios (HRs) for mortality and subdistributional hazard ratios (sHRs) for reoperations are shown with 95% confidence intervals (CIs). Results. A total of 17,671 patients with primary HA were identified (9,484 uncemented and 8,187 cemented HAs). Compared to uncemented HA, surgery with cemented HA was associated with an absolute risk difference of 0.4% for mortality within the period zero to one day after surgery and an adjusted HR of 1.70 (95% CI 1.22 to 2.38). After seven days, there was no longer any association, with an adjusted HR of 1.07 (95% CI 0.90 to 1.28). This continued until five years after surgery with a HR of 1.01 (95% CI 0.96 to 1.06). There was a higher proportion of reoperations due to any reason after five years in the uncemented group with 10.2% compared to the cemented group with 6.1%. This yielded an adjusted sHR of 0.65 (95% CI 0.57 to 0.75) and difference continued up until five years after the surgery, demonstrating a sHR of 0.70 (95% CI 0.59 to 0.83). Conclusion. In a non-selected cohort of hip fracture patients, surgery with cemented HA was associated with a higher relative mortality during the first postoperative day compared to surgery with uncemented HA, but there was no difference after seven days up until five years after. In contrast, surgery with cemented HA was associated with lower risk of reoperation up to five years postoperatively compared with surgery with uncemented HA. There was a higher relative mortality on the first postoperative day for cemented HA versus uncemented HA. There was no difference in mortality after seven days up until five years after surgery. There were 6.1% reoperations for cemented HA compared to 10.2% for uncemented HA after five years. Cite this article: Bone Joint J 2022;104-B(1):127–133

Aims. The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR). Patients and Methods. A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours. Results. Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours. Conclusion. Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129–1137

Hip fractures are a common cause of morbidity and mortality in the elderly, with approximately 30,000 hip fractures a year in Canada. Many hip fracture patients are prone to heart failure and present anticoagulated with Warfarin for medical comorbidities including atrial fibrillation or previous thromboembolic disease. Reversal of warfarin anticoagulation to an INR < 1.5 preferred for surgery but this often contributes to a delay to hip fracture surgery, which increases patient pain, morbidity, mortality, and length of stay Octaplex is a small-volume prothrombin complex concentrate (PCC) that reverses Warfarin-related anticoagulation in 15–60 minutes. It has been shown to be safe and effective in the management of intracranial and gastrointestinal bleeding in warfarinised patients. It is recommended by Bone and Joint Canada as an option for urgent warfarin reversal in hip fracture patients. However, there has been no published literature on the use of Octaplex or other PCCs in orthopaedic patients. Our objective is to assess the effectiveness of Octaplex for rapid reversal of warfarin anticoagulation in hip fracture patients. A database review of all patients who received Octaplex was performed. Medical records of all hip fracture patients in Calgary who received Octaplex between December 2009 and February 2015 were reviewed. After application of inclusion and exclusion criteria, 33 patients were identified. A timeline of International Normalised Ratio (INR), Octaplex administration, and hip fracture surgery was recorded. Mortality and complications were assessed at 30 days. A single dose of Octaplex corrected the INR to < 1.5 in 29 cases (88%). Median time from administration of Octaplex to a measured INR < 1.5 was 1.1 hours. Median time from admission to hip fracture surgery was 22 hours. Mortality at 30 days was 15.2%, mostly from cardiac arrest. A further 12% of patients developed cardiac or thrombotic complications. Multiple medical comorbidities were common including coronary artery disease (55%), congestive heart failure (45%), and chronic pulmonary disease (39%). Patients who received both fresh frozen plasma (FFP) and Octaplex for warfarin reversal had much higher mortality than those who only received Octaplex (40% vs 4.3% mortality at 30 days), but also had more medical comorbidities. Octaplex is effective at rapidly reversing warfarin anticoagulation and reducing time to surgery, potentially reducing the morbidity and mortality of hip fractures. Administration of both Octaplex and FFP were associated with higher early mortality in this case series. Further research is required to assess the safety of Octaplex, vitamin K, and FFP for reversal of warfarin anticoagulation in this population

Introduction. A fractured hip is the commonest cause of injury related death in the UK. Prompt surgery has been found to improve pain scores and reduce the length of hospital stay, risk of decubitus ulcer formation and mortality rates. The hip fracture Best Practice Tariff (BPT) aims to improve these outcomes by financially compensating services, which deliver hip fracture surgery within 36 hours of admission. Ensuring that delays are reserved for patients with conditions which compromise survival, but are responsive to medical optimisation, would facilitate enhanced outcomes and help to achieve the 36-hour target. We aimed to identify medical conditions associated with patients failing to achieve the 36-hour cut off, and evaluated whether these were justified by calculating their associated mortality risk. Methods. Prospectively collected data from the National Hip Fracture Database (NHFD) and inpatient hospital records and blood results from a single major trauma centre were obtained. Complete data sets from 1361 patients were available for analysis. Medical conditions contributing to surgical delay beyond the BPPT (Best Practice Tariff Target) 36-hour cut off, were identified and analysed using univariate and multivariate regression analyses, whilst adjusting for covariates. The mortality risk associated with each factor contributing to surgical delay was then calculated using univariate and hierarchical regression techniques. Results. A total 1,361 patients underwent hip fracture surgery, of which 537 patients (39.5%) received surgery within 36- hours of admission. The overall median time to surgery from presentation was 23 hours (range 3–36) in patients who did (group 1) and 72 hours (range 36–774) in those who did not (group 2) receive timely surgery. There was no difference between the two groups with respect to age, gender, walking ability, fracture pattern and ASA grade. Following univariate analysis, seven variables including admission source, history of dementia, ischaemic heart disease, MI, cerebrovascular accidents (CVA), urinary tract infections and hyponatraemia met criteria for inclusion into the Cox regression model. The model thereafter revealed only hyponatraemia to be a significant determinant of delay to surgery beyond 36 hours with a covariate adjusted relative risk (RR) 1.24 (95% CI 1.06 – 1.44, p=0.006). The overall 30- day mortality in our cohort of hip fracture patients was 9.0%. The commonest cause of death was pneumonia (37%). A second stage hierarchical cox model failed to demonstrate hyponatraemia as being a predictor of 30- day mortality after adjusting for significant co-variants (RR=0.944, CI 95% 0.616–1.447, p=0.793). Conclusions. Hip fracture surgery should not be delayed in the presence of non-severe and isolated hyponatraemia. Instead surgical delay should be reserved for medical conditions, which contribute to mortality and are optimisable

Aims

Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture.

The August 2023 Trauma Roundup³⁶⁰ looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

The effect of early surgery on hip fracture outcomes has received considerable study and although it has been suggested that early surgical treatment of these fractures leads to better patient outcomes, the findings are inconclusive. The American College of Surgeon's (ACS) National Surgical Quality Improvement Project (NSQIP) prospectively collects blinded, risk-adjusted patient-level data on surgical patients in over 600 participating hospitals worldwide. The primary objective of this study was to determine the proportion of ACS-NSQIP hospital patients that are currently being treated within the UK's National Institute for Health and Care Excellence (NICE) time to hip fracture surgery benchmark. The secondary objectives were to identify risk factors for missing the benchmark, and determine if the benchmark is associated with improved 30-day patient outcomes. Patients that underwent hip fracture surgery between 2005–2013 and entered in the ACS-NSQIP database were included in the study. Counts and proportions were used to determine how frequently the NICE benchmark was met. Multivariate regression analysis was used to identify significant predictors of missing the NICE benchmark and determine if missing the benchmark was associated with 30-day mortality/complications rates. 26,006 patients met the study enrolment criteria. 71.4% of patients were treated within the NICE benchmark and 89.4% were treated by post-admission day two. Gender, dyspnea, infectious illness, bleeding disorders, preoperative hematocrit, preoperative platelet count, arthroplasty procedure type, race other than White, and hip fracture diagnosis were all statistically significant predictors of missing the benchmark (p<0.01). Meeting the NICE benchmark was not associated with reductions in major complications (OR=0.93, CI=0.83–1.05, p=0.23), nor a clinically significant difference in postoperative length of stay (LOS) (parameter estimate=0.77, p<0.01); however, it was associated with a decreased 30-day mortality (OR=0.88, CI=0.78–0.99, p=0.03) and the likelihood of minor complications (OR=0.92, CI=0.84–0.995, p=0.04). ACS-NSQIP hospitals are currently compatible with the NICE benchmark. However, data from the ACS-NSQIP database suggests that surgical treatment within the NICE benchmark may be unnecessarily narrow. Extending the benchmark to post-operative day two did not significantly increase the risk of 30-day mortality and minor complications; nor did it extend the average LOS. Neither the NICE benchmark, nor the extended two-day standard, was associated with reductions in major complications. The findings highlight the importance of further prospective investigation to monitor the effect of time to surgery benchmarks

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

The December 2022 Hip & Pelvis Roundup³⁶⁰ looks at: Fix and replace: simultaneous fracture fixation and hip arthroplasty for acetabular fractures in older patients; Is the revision rate for femoral neck fracture lower for total hip arthroplasty than for hemiarthroplasty?; Femoral periprosthetic fractures: data from the COMPOSE cohort study; Dual-mobility cups and fracture of the femur; What’s the deal with outcomes for hip and knee arthroplasty outcomes internationally?; Osteochondral lesions of the femoral head: is costal cartilage the answer?

Aims

To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

Aims

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

Aims

Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA.

Aims

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

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum. Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant

Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of postoperative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery. 28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MESs) were recorded during the operative procedure. Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MESs had undergone a cemented hemiarthroplasty; the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients who had a cemented hemiarthroplasty had the majority of MESs after reaming and cementing. MESs in the patients who had a sliding hip screw occurred throughout the operative procedure. Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients

Introduction and Aims: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery. Method: Twenty-eight patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MESs) were recorded during the operative procedure. Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. Twelve out of 16 patients who had MESs had undergone a cemented hemiarthroplasty, the remainder had a sliding hip screw for an extracapsular hip fracture. Seventy-five percent (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MESs after reaming and cementing. MESs in the patients that had a sliding hip screw occurred throughout the operative procedure. Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients

Aims

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

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Background: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery. Method: 28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MES’s) were recorded during the operative procedure. Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MES’s had undergone a cemented hemiarthroplasty the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MES’s after reaming and cementing. MES’s in the patients that had a sliding hip screw occurred throughout the operative procedure. Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients

Aims. This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation. Patients and Methods. Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year. Results. Of 43 dislocations, 30 (70%) occurred within one month and 42 (98%) occurred within three months of hip fracture surgery. Seven (16%) of these patients were treated with a single closed reduction and sustained no further dislocations. Four (9%) were treated with open reduction and experienced no further dislocations. Three (7%) hips were left dislocated and the remaining 32 (74%) patients required additional surgery of further closed reduction, revision, or excision arthroplasty. The one-year mortality rates for patients treated with two or fewer reductions (open or closed), successful revision arthroplasty, and excision arthroplasty were 3/14 (21%), 1/7 (14%), and 8/14 (57%) respectively. The only statistically significant difference in mortality was the difference between patients who did not sustain a dislocation and those who did and were treated by excision arthroplasty (p = 0.03). Patients treated by excision arthroplasty had the greatest reduction in mobility scores and highest pain scores. The excision arthroplasty group also included the greatest proportion of patients not able to mobilize and the smallest proportion of patients remaining in their own home. Conclusion. Most dislocations of hemiarthroplasties of the hip occur within one month of surgery. Closed reduction is generally unsuccessful. For those patients with unsuccessful closed reduction, revision arthroplasty should be considered when possible, as this results in a better functional outcome with a lower mortality than excision arthroplasty

Aim: Our aim was to find the effect of implementation of European working time directive on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum. Methods: The audit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of the this and have identified a potential area of concern. Results: An orthopaedic trainee of registrar level(Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non-training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There is a definite trend suggesting decrease in number of operations by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view. Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP

Aims

To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment.

Evidence suggests as little as 32percnt; of those with a displaced intracapsular hip fracture who meet the NICE eligibility criteria currently undergo a total hip replacement (THR). The reason for this discrepancy is not clear. This study therefore set out to examine the reasons behind this lack of adherence to these guidelines through the use of a questionnaire to current Trauma & Orthopaedic surgery consultants across Scotland. An invitation to take part in the survey was distributed through the Scottish Committee for Orthopaedics & Trauma (SCOT) email address list. A series of 10 questions were designed to determine the background of participants, their experience at performing hip fracture surgery (including THR) and their thoughts regarding its use in the hip fracture setting. Results were collated at the end of the study period and quantitatively analysed where possible. There were 91 responses in total. 53percnt; of individuals said they would offer those meeting the NICE criteria a THR less than 76percnt; of the time. The most commonly used alternative was a cemented bipolar hemiarthroplasty (51percnt;). Hip surgeons were more likely to perform or supervise THR for hip fracture than non-hip surgeons (p<0.0001). There were a wide variety of reasons why people would not offer a THR including dislocation rate, technical complexity and inadequate evidence for use. Overall this study highlights current trends and barriers in the provision of THR to hip fracture patients. This knowledge can be used to ascertain research priorities to maximise the quality of care in this setting

The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture

Objectives. Aged trauma patients are at high risk for various comorbidities and loss of function following hip fracture. Consequently a multidisciplinary approach for the treatment of these patients has become more famous in order to maintain the patients” activity level and health status prior to trauma. This study evaluates the effect of a multidisciplinary inpatient rehabilitation on the short- and long-term functional status of geriatric patients following hip fracture surgery. Methods. A collective of 158 hip fracture patients (> 80 years) who underwent surgery were included in this study. An initial Barthel Index lower than 30 points was a criteria to exclude patients from this study. Two subgroups, depending on the availability of treatment spots at the rehabilitation center were made. No other item was used to discriminated between the groups. Group A (n=95) stayed an average of 21 days at an inpatient rehabilitation center specialized in geriatric patients. Group B (n=63) underwent the standard postoperative treatment. As main outcome parameter we used the Barthel Index, which was evaluated for every patient on the day of discharge and checkups after three, six and twelve months. Results. After three months, the average Barthel Index was 82,27 points for group A and 74,68 points for group B (p=0,015). In the six-months-checkup group A”s average Barthel Index was 84,05 points and group B”s was 74,76 points (p=0,004). After twelve months, patients from group A had an average Barthel Index of 81,05 while patients from group B had an average Barthel Index of 71,51 (p=0,010). Conclusion. This study reveals a significant better outcome in both, the short-term and the long-term functional status for geriatric hip-fracture patients, who underwent an inpatient treatment in a rehabilitation center following the initial surgical therapy. This is shown at the timepoints three, six and twelve month after discharge. To maintain quality of life and mobility as well as the patient”s independence in daily life, a treatment in a rehabilitation center specialized in geriatric patients is highly recommendable

Aims

Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature.