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.

Background and Purpose: The New Mobility Score (NMS)(score from 0–9)(1) is being used to evaluate the prefracture functional level and to predict for example mortality in hip fracture patients. Previous studies have found or used a cut-off point of the NMS at 5, but reliability data of the NMS score is currently missing. Reliability refers to the consistency of a test or measurement and it can be quantified as either relative or absolute reliability. Relative reliability is often expressed by the intraclass correlation coefficients (ICC), which indicate the relationship between 2 or more measures of the same score. Absolute reliability is often expressed by the standard error of measurement (SEM). SEM quantifies the precision of individual scores on a test and gives the clinician a result in the same unit as the measurement. The aim of the study was to assess the inter-tester reliability of the NMS in acute hip fracture patients, when obtained by physicians and physiotherapists.

Subjects: Forty eight consecutive hip fracture patients at a median age of 84 (IQR, 76–89) years admitted to a specialized orthopaedic hip fracture unit at a university hospital.

Methods: The NMS, that describes the prefracture functional level, 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 NMS was assessed by physicians at the acute ward on admission and by two independent physiotherapists at different postoperative days at the stationary orthopaedic ward. Also, age, mental status on admission and residential status was recorded. The relative reliability was calculated using the ICC 1.1, while the absolute reliability was calculated using the SEM.

Results: The inter-tester reliability was higher between the two physiotherapists at the stationary ward (ICC 0.98) and (SEM 0.42) (95%CI + 0.82) compared to, between physicians at the acute ward and both physiotherapists (ICC 0.87) and (SEM 1.05) (95%CI + 2.06). No systematic between-rater bias was observed (P > 0.05). Patients with different recorded scores were significantly older (P < 0.023) and had lower NMS-scores than those with equal recorded scores.

Conclusion: The relative and absolute reliability of the NMS, when used in acute hip fracture patients, is very high, especially when the score is recorded by physiotherapists at the stationary orthopaedic ward. Ward personal should be extra careful when recording the NMS in subjects with older age and lower NMS and mental scores.

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: 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: 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.

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.