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

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In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

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The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Purpose. The purpose of this study was to prospectively evaluate the rehabilitation outcome of children following operative and non-operative stabilisation of long bone fractures sustained in conjunction with an acquired brain injury (ABI). Materials and Methods. Between 1996 and 2002, children up to 16 years of age who were admitted to the Paediatric Intensive Care Unit (PICU) with an ABI and concomitant tibial or femoral shaft fractures were considered eligible for inclusion. Children who died or were unable to walk before the accident were excluded. All data relating to the sustained injuries, the duration of PICU inpatient stay, the fracture treatment and the functional outcome were collected prospectively. The severity of the injuries was assessed using the Injury Severity Score (ISS) and the Glasgow Coma Score (GCS). The duration of time was taken from admission to reaching rehabilitation milestones; the ability to sit, stand and walk was then assessed. Total duration of hospital inpatient stay and mobility on discharge were also recorded. Operative skeletal stabilisation included external or internal fixation, as well as flexible intramedullary nailing. Statistical analysis was performed using the Mann-Whitney U Test. Results. From 300 children admitted to the PICU for treatment of ABI, thirty-seven fulfilled the criteria for inclusion into the study. For both groups (operative vs nonoperative treatment) the mean age of patients was 9 years (range 1–15yrs) and the ISS, GCS scores and the mean stay in PICU were similar. There was a total of 21 femoral fractures (11 treated conservatively and 10 operatively) and 16 tibial fractures (7 conservatively and 9 operatively). Overall, the results showed a reduction in the mean time taken to reach all rehabilitation milestones following operative fracture stabilisation when compared to those treated non-operatively. The mean time to sitting was reduced from 27.1 days to 17.8. The mean time to standing was reduced from 50.1 to 35.6 and to walking, from 67.1 to 45.7 days. The Mann-Whitney U Test demonstrated a statistically significant reduced time to walk in the operatively treated group (p<0.05). Due to the small size of the sample group, significant statistical data for the other parameters measured was not evident. Conclusion. This study was specifically aimed at the short to medium term gains of operative treatment of tibial and femoral fractures in association with ABI. It has been shown that a co-ordinated rehabilitation programme plus operative stabilisation of children's tibial and femoral shaft fractures sustained in association with ABI, hastens rehabilitation, as it allowed aggressive rehabilitation programme to commence at a much earlier stage without risk of loss of fracture reduction

We report a cost-effectiveness analysis of Primary Total Ankle Replacements (TAR). In addition, we looked for factors that could be predictors of increased gain in Quality-Adjusted Life Years (QALYs). Pre-operative and six-month post-operative data for TAR was obtained over seven-and-a-half-years in NHS Lothian. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and Deprivation category. Continuous variables were assessed with Pearson correlation coefficients, Deprivation and BMI categories with Boxplots and gender with the Mann-Whitney U test. The 74-patient cohort [Mean age 68.03 (SD 8.61), 60.8% male] had 49% classed as obese or higher. Cost per QALY gained was £3841, rising to £9202 when annual 3.5% reduction in health gains and 1.9% revision rates were included. Lower pre-operative EQ-5D-3L index correlated significantly with increased QALYs gained (p <0.01), all other predictors returned insignificant results (p >0.05). Primary TAR has proven very cost-effective in treating end-stage ankle arthritis. Pre-operative EQ-5D-3L is the most promising predictor of QALYs gained identified

There is evidence that fracture healing is delayed in severely injured patients. We recently demonstrated that a blunt chest trauma, which induced posttraumatic systemic inflammation, considerably impaired fracture healing in rats. Because the complement anaphylatoxin C5a is an important trigger of systemic inflammation, we tested the hypothesis, whether the impairment of fracture healing observed after a severe trauma resulted from systemically activated complement. 16 male Wistar rats received a thoracic trauma and a femur osteotomy stabilized by an external fixator. Immediately and 12 h after the trauma, half of the animals received a C5aR-antagonist to prevent the C5a-dependent systemic inflammation. Control rats received a nonsense peptide, which does not provoke any biological effect. The animals were killed after 35 days and the calli were analyzed by three point bending testing, μCT and histomorphometry. Statistics: Mann-Whitney U test, level of significance to p<0.05. The treatment with the C5aR-antagonist increased flexural rigidity significantly by 55%, improved bony bridging of the fracture gap and led to a slightly larger and qualitatively improved callus as evaluated by μCT and histological measurements. This study shows, that the immunomodulation by a C5aR-antagonist significantly reduced the deleterious effects of a thoracic trauma on fracture healing. C5a could possibly represent a target to prevent delayed bone healing in patients with severe trauma

Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patient's ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patient's recall of the risks associated with their surgery. 121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process. Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was significantly improved in the group receiving written and verbal information, 97.9% of patients reported that they understood the risks of surgery when they signed the consent form compared to 83.2% who received verbal information alone (p=0.01). The majority of patients who received written information reported finding it helpful (93.8%) and most of the patients who did not receive written information reported they would have found it useful had it been offered (66%). Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients

Introduction. Pre-operative patient education prior to hip and knee arthroplasty is thought to be beneficial for patients in general, although the clinical effect is unproven. Pre-operative education is now standard practice in many orthopaedic units, including our own. Anecdotally, we found patients in the private sector to be more satisfied with their education than those in the public sector, despite very similar education programs. We set out to investigate this observation and establish whether there were differences in the perception of educational quality between these groups. Methods. After appropriate power calculation, 60 patients in each group (120 total) were interviewed after hip or knee arthroplasty. Satisfaction with education was assessed on a simple 5 point scale and demographic data including internet access was obtained, as well as Short-Form 12 (SF-12) data to establish physical and mental function. The education program in each group was similar, with written material provided and verbal education given at a single pre-operative session. This included specialist nursing and physiotherapy input. Results were analysed with the chi2 test, Mann-Whitney U test and logistic regression as appropriate, with significance at P<0.05. Results. Overall, there was a high level of satisfaction in both groups but patients in the private sector were significantly more satisfied with their pre-operative education. Significant differences were identified between the groups in provision of written information, provision of internet resources, access to the internet, attendance at education sessions and the mental component score of the SF-12. Logistic regression modelling showed that factors influencing satisfaction rates were interdependent. The relationship between lower SF-12 mental component scores and lower satisfaction rates was linear. Conclusion. Private patients are more satisfied with their pre-operative education than public patients, a disparity which may be due to several demographic and educational factors including lower SF-12 mental component scores. The relationships between these factors are complex and not independent. Satisfaction in the public sector may be improved by improving attendance rates at education sessions. However, public patients may not benefit from advances in education that rely on internet access or computer use. Although the use of the internet and computers in general is gaining support, it may not be as beneficial to patients in the public sector as the private sector. This has implications for service provision and planning in arthroplasty units

Background. Though less common than in females, osteoporosis and osteoporosis-related fractures are not uncommon in males. Our primary objectives were (1) to compare the rates of osteoporosis and osteopenia in adult Brazilian males versus females, 55 years old and over and presenting for bone mineral densitometry (BMD); and (2) to compare males and females as to past osteoporosis screening and management. Methods. From our clinic population, we prospectively surveyed 343 males and 493 females, all at least 55 years of age, who had presented for BMD testing, to identify baseline demographic and clinical characteristics; risk factors for osteoporosis and osteoporotic fractures; overall osteoporosis and 10-year fracture risk; and evidence of prior assessment for and/or management/prevention of osteoporosis. Final osteoporosis risk was determined using the results of BMD testing and the FRAX® tool. Gender comparisons were performed using Pearson 2 analysis for nominal and ordinal variables, Student's t-tests for normally-distributed continuous variables, and Mann-Whitney U tests for non-normally-distributed continuous variables, with all tests 2-tailed and p=0.05 set as the threshold for statistical significance. Binary logistic regression was performed to identify predictors of prior hormonal treatment and BMD. Results. There were no differences in the rates of prior fracture, spinal fracture or long-bone fracture between the sexes, though women were more likely to have osteoporosis of the spine and femur, and had higher estimated risks of future osteoporotic fracture (all p < 0.001). Women also were significantly more likely to have received treatment for their osteoporosis (7.9 vs. 3.1%, p=0.004) and to have had prior BMD testing (80.7 vs. 16.2%, p < 0.001). Ten-year probabilities of hip fracture were 4.8% in males and 5.2% in females; and for a major osteoporotic fracture 5.6% and 24.3%., respectively (both p < 0.001). Age, gender and spinal osteoporosis predicted prior hormonal treatment; but gender was the only predictor of prior BMD, with males 95% less likely to have undergone prior testing than females. Conclusions. Despite similar past fracture rates, and lower but still appreciable future fracture risk, far fewer males than females had received prior screening or management of their osteoporosis

INTRODUCTION. Autologous bone grafts are considered gold standard in the repair of bone defects. However they are limited in supply and are associated with donor site morbidity. This has led to the development of synthetic bone graft substitute (BGS) materials, many of which have been reported as being osteoinductive. The structure of the BGS is important and bone formation has been observed in scaffolds with a macroporous morphology. Smaller pores termed ‘strut porosity’ may also be important for osteoinduction. The aim of this study was to compare the osteoinductive ability of one silicate-substituted calcium phosphate (SiCaP) with differing strut porosities in an ectopic ovine model. Our hypothesis was that SiCaP with greater strut porosity would be more osteoinductive. METHODS. The osteoinduction of SiCaP BGS with two different strut porosities (AF and AF++) was investigated. The materials had an identical chemical composition and morphological structure but differing strut porosity (AF=22.5%, AF++=47%). Implants were inserted into the paraspinal muscles in skeletally mature sheep. Procedures were carried out in compliance with UK Home Office regulations. There were 12 implants in each group. Implants remained in vivo for 8 and 12 weeks and on retrieval were prepared for undecalcified histology. Sections were stained and examined using light microscopy. A line intersection method was used to quantify bone, implant and implant surface/bone contact within seven random regions of interest along each implant. A Mann-Whitney U test was used for statistical analysis where p values < 0.05 were considered significant. RESULTS. Bone formation was observed to be greater in the AF++ group at 8 (AF=0.2%+/−0.15; AF++=0.44%+/−0.12) and significantly higher at 12 weeks (AF=1.33% +/−0.84; AF++=6.17%+/−1.51) (p=0.04). Significantly higher implant surface/bone contact was observed in the AF++ group at 8 (AF=0.67%+/−0.52; AF++=3.30%+/−1.17) (p=0.04) and 12 weeks (AF=3.06%+/−1.89; AF++=21.82%+/−5.59) (p=0.01). The % implant measured was less in the AF++ group at 8 (AF=39.06%+/−1.26; AF++=33.09%+/−2.14) and 12 weeks (AF=36.05% +/−3.55; AF++=30.60%+/−2.29) but this was not significant. Histology revealed bone formation within BGS strut pores measuring < 50um. Endochondral and intramembranous ossification were also observed in both groups. DISCUSSION. The results indicate that higher strut porosity promotes greater osteoinduction in SiCaP materials. This could be attributed to the micropores providing a greater surface area for the action of growth factors and osteoblasts leading to the formation of bone at an earlier time point. Endochondral ossification was an unusual finding as this is usually associated with bone formation secondary to Bone Morphogenetic proteins (BMPs). This suggests that the osteoinductive mechanisms by SiCaP may involve cytokines such as BMPs

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The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial.

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Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

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To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients.

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Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

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The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients.

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We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function.

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The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

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The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

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The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

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