Background and purpose: As hip fracture patients are common and constitute an increasing health problem it is important to use available resources effectively and provide high quality care. Correct treatment can start in the ambulance with administration of oxygen, pain relief and intravenous glucose liquid according to the Lean Production concept. The basis of Lean Production is that the employees themselves develop their work as a natural part of the job. In the case of health care, this involves learning what it are that really benefits the patients, what it is that creates added value. Anything that does not benefit the patients is to be removed.

The aim of this study was to improve the preopera-tive care of hip fracture patients.

Subjects : During the period 2007-04-01 to 2007-12-31 totally 365 hip fracture patients were consecutively admitted to the University Hospital. Of them 117 (mean age 82.8) patients were included in the project and 248 patients (mean age 81.3) were controls.

Method: Patients with a suspected hip fracture (shortened and externally rotated leg) were supposed to be included in the study. Exclusions criteria were medical unfit patients with for example ongoing hearth problems or stroke. Already in the ambulance the patient’s identification was established, blood samples were drawn and electrocardiography was taken. At admission to the hospital the ambulance personnel directly followed the patient to the x-ray unit and further to the orthopaedic ward without passing the acute and emergency unit.

Results: Patients included in the project felt that they were in safe hands and were satisfied with the handling time from the ambulance until they were at the ward. This time has diminished from 4 hours to half a hour. The mean time from admission to surgery was 29 hours for patients in the control group versus 21 hours for patients included in the project. Furthermore, the personnel at the x-ray unit are satisfied with the new organisation since there are more personnel lifting a better pain relieved patient from the trolley to the x-ray table.

Conclusion: When we are working in multi professional and multi functional teams with the LEAN concept, safety and quality of care can be improved if the preop-erative care of hip fracture patients is speeded up.

Due to an ageing population the numbers of patients with hip fractures are increasing. They often suffer from concomitant diseases and are therefore prone to be affected by complications such as pressure ulcers. The prevention of pressure ulcers among patients with a hip fracture is crucial. The aim of this study was to improve the quality of care and patient safety in patients with a hip fracture. A new evidence based clinical pathway was introduced to prevent hospital acquired pressure ulcers. Furthermore the purpose was to bring the staff’s attention to pressure ulcer prevention and to facilitate changes in clinical practice to improve quality of care and patient safety. A total of 478 patients with a hip fracture were consecutively included between April 1st 2003 and March 31 st 2004. The new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. In the intervention group hospital acquired pressure ulcers decreased by 50% (p< 0.007). It is possible to reduce the development

Background and Aims: Patients with a hip fracture often have a poor nutritional status which is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention.

Methods: A quasi-experimental study of 478 patients consecutively included between April 1st 2003 and March 31st 2004. A new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article.

Results: The total number of patients with a hospital acquired pressure ulcer was in the intervention group, 19 patients, and in the control group 39 patients (p=0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p=0.05), calf circumference (CC) (p=0.038) and body mass index (BMI) (p=0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) < 10th percentile and AMC < 10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the four patients in the intervention group developed pressure ulcers. However two of the 12patients in the control group were affected.

Conclusions: It is possible to reduce the development of hospital acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. The results in this study indicate the value of the new clinical pathway, as the number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.

Hip fractures constitute a major cause of hospital admission and length of stay in the elderly, resulting in increased disability and mortality. In this study the influence of optimized treatment of consecutively included patients with hip fracture on time to operation, bed days, reoperations and mortality within one year were investigated. The study period was April 1st 2003 and March 31st 2004. Comparisons are made between the 210 first patients and the 210 last patients who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24 hours, was not associated with reduced mortality, but it was significantly associated with reduced length of stay (p< 0.001). Significantly more patients operated with osteosynthesis for femoral neck fracture, were reoperated compared to all other types of surgery (p< 0.001) also when reoperations with extraction of the hook-pins in healed fractures were excluded. Mortality was higher in men than in women at four (p = 0.025) and twelve months (p = 0.001) after the fracture. Mortality was significantly higher in medically fit patients with administrative delay to surgery compared to patients with no delay (p< 0.001).

The health care system has to deal with substantial health care costs, which are expected to continue to rise due to the increasingly elderly populations. One way of saving has been a reduction of the amount of beds at hospitals. The consequence is that acute patients inappropriately are admitted to non specialized wards because of limited beds. These patients are also known as ‘outliers’. In this study consecutive patients with a hip fracture treated at the orthopaedic department (n=273) are compared with patients treated at other departments (n=147) according to incidence of complications and length of stay (LOS) before and after introduction of an evidence based clinical pathway. There was no medical difference between the populations. However the strict demands of saving costs, with limited beds, have resulted not only in economic consequences with prolonged hospitalization, but also in patient suffering and inconvenience of postoperative complications because of an increasing number of complications.

Patients treated at non specialized wards had an extra LOS of stay of 3.7 days in the acute hospital settings and furthermore 13.6 days of LOS including rehabilitation compared to patients treated at the orthopaedic department. In addition we consider the implemented evidence based clinical pathway to be successful since the number of complications was reduced. It is a major challenge to establish effective treatment and rehabilitation for patients after a hip fracture aiming to avoid complications and reduce LOS. Theses fragile patients with a hip fracture ought to be treated at the orthopaedic department, or at departments with geriatric and rehabilitation knowledge. Physiotherapists, occupational therapists and nurses specialising in orthopaedics and geriatricians should take an active part in these patients care, to improve the quality of care and patient safety in patients with a hip fracture.

PURPOSE: Patients who sustain fall-related distal forearm fractures are at risk to sustain new fractures later in life. Risk factors for falls such as low physical activity, impaired gait and neuromuscular function, and comorbidity are well known, as well as risk factors for fractures such as female gender, old age, low body mass index (BMI) and low mobility. Fracture prevention is often directed toward bone mass density treatment, but there is evidence that high level of physical activity reduces falls and therefore also reduces fractures. Health related quality of life (HRQoL) has become an important additional measure. The aims of this study were to evaluate the HRQoL, reported with EQ-5D and SF-12, in women who had sustained fall-related distal forearm fracture one year earlier and compare with Swedish normative data, and to physical performance and self-reported comorbidity.

PARTICIPANTS: Sixty women with a fall-related distal forearm fracture were invited to examine health-related quality of life and physical performance at a mean time of 13 months after they had sustained their fracture (S.D. 1.6, range 10–17). The inclusion criteria were that they should be able to perform the physical tests and to understand verbal and written Swedish. Forty three women (72%), mean age 68 (SD 8.4, range 50–84), agreed to participate.

METHODS: The women filled in two generic HRQoL-questionnaires; EQ-5D and SF-12. They self-rated their physical activity and reported ailments, which were regularly examined by a doctor, and intake of prescribed medication. They reported problems or difficulties from the locomotor system and depressive symptoms during the three last months. All women underwent physical performance tests; handgrip strength, one leg standing (OLS) and walking speed. Fisher’s exact test, Mann Whitney U test and Spearman’s rank correlation coefficient were used in the statistical analyses.

RESULTS: In the younger women (age 50–59) the HRQoL was lower compared to Swedish normative data. The EQ-5D index and VAS scores correlated moderately to the physical component summary (PCS-12) of the SF-12 (rs=0.73 and rs=0.69, respectively). The correlation to the mental component summary (MCS-12) of the SF-12 was lower (rs=0.32 and rs=0.22, respectively). Women who reported comorbidity and low physical activity scored lower in the corresponding items of health in both questionnaires.

CONCLUSIONS: Low results in HRQoL questionnaires in apparently healthy older women with fall-related distal forearm fracture may indicate underlying comorbidity, not captured by physical performance tests. We suggest that HRQoL questionnaires should be used in additional to physical outcome measures for this patient group. The use of HRQoL questionnaires to find patients for preventive measures of falls and fractures should be further explored.

We studied prospectively the change over ten years in mortality, walking ability and place of residence after a hip fracture in 753 patients in Japan. We compared the deaths observed in these patients with those expected in the general population, matched for age, gender and calender year at the time of fracture. The survival rate decreased dramatically for two years after the event and the mortality risk remained higher for ten years. This risk was approximately double that of the general population, even at ten years after fracture. The risk was higher, and remained so for longer, in younger rather than in older patients.

The proportion of patients who were able to walk outdoors alone, with or without an assistive device, was 68% (514) before fracture. This decreased to 56% (340) by one year after and remained stable at approximately 63% (125) until ten years. The proportion of patients living in their own home was 84% (629) before fracture, 81% (491) one year later, and then remained stable at approximately 86% (171) until ten years after the event.

In the trend to operate hip fractures with less invasive procedures it is important to realise that the semi-percutaneous approach to make osteosynthesis with two screws or hook pins for femoral neck fractures, actually is a mini invasive procedure. It is well proven since decades.

The major question is to select the right patients for osteosynthesis versus arthroplasty (unipolar hemi, bipolar hemi or total hip arthroplasty). It is depending on the damage to the blood supply of the femoral head. There is at the moment no methods for this in routine use, but with the development of MRI techniques it might be possible. The goal is to select the right patients for osteosynthesis to minimise the healing complications and the need for secondary hip arthroplasties.

The hook pin procedure has been extensively used in Sweden through decades. Since the last 5 years there is an increasing trend for the most displaced fractures in older patients to be operated with a hemi arthroplasty. Previously a primary osteosynthesis was the first choice in all patients. The results of 10 years use of this procedure in Lund 1988–1997 shows that for the total of femoral neck (cervical) hip fractures the need for a secondary arthroplasty within 2 years was 20%. Previously published need for secondary arthroplasty was 13% when only well trained surgeons operated. There is thus no need to behead all displaces femoral neck fractures because some fail. In Norway the principles of primary osteosynthesis still mostly prevail. In a randomised comparison between hook pins and screws it was found that the rates of early failure of fixation, non-union and need for reoperation did not differ significantly between the two osteosynthesis methods. The use of hook pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6) and a lower incidence of necrosis of the femoral head (odds ratio 3.5). The technique of performance was of significant importance. There was a highly significant relationship between poor reduction and poor fixation of the fracture and subsequent reoperation. Likewise per-operative drill penetration of the femoral head was associated with a greater risk of reoperation. In total 22% of these patients needed a major reoperation (usually hemi arthroplasty). In 7% of the cases the fixation device needed to be removed after a healed fracture. In another randomised study between hook pins and three screws 57% of the patients were operated within 6 hours from admission to hospital and 92% within 24 hours. The mean (median) time for operation was 36 (30) minutes for the hook pins and 40 (35) minutes for the AO screws. After 2 years 77% of the hook pin patients had not needed any reoperation compared to 73% in the AO screw group. In total a secondary hemiarthroplasty had been performed in 7% and a total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. Again, healing was much higher if the reposition and positioning of the osteosynthesis material was optimised.

Osteosynthesis is a mini invasive procedure. It is indicated for all undisplaced cervical fractures and for less displaced fractures, particularly in younger patients. Attention to the reposition and positioning of the osteosynthesis material is necessary. An image intensifier with large field of view and good resolution facilitates this, preferably a biplanar. The future goal is to select the patients better for the different procedures osteosynthesis or arthroplasty.

It is important to optimise not only the operative treatment, but also the general medical condition of hip fracture patients to achieve the best rehabilitation result. Patients with a hip fracture are old and often suffer from concomitant diseases. They are prone to be affected by complications such as pneumonia, urinary tract infection and pressure ulcers. The total treatment situation with sufficient intake of food and drink, pain management, prevention of pressure ulcers and a rapid handling from arrival at the Acute and Emergency unit until the patient has been operated is crucial. We have studied the nutrition and drink in patients with a hip fracture and in spite of repeated instructions to eat and drink sufficiently the patients with the hospital standard food achieve only 54% of their optimum energy needs and 64% of the fluid necessary. With an extra addition of nourishment to the hospital food the total energy and fluid intake reach almost the calculated level of need for these patients. The amount of complications, particularly infections, were significantly lower in the well nourished group.

We have also started to optimise the immediate acute treatment and already in the ambulance the patients now receive pain treatment, intravenous fluid and oxygene administration. The patients receive 3 litres of oxygene/min preoperatively and the first days postoperatively. The waiting time on hard surfaces has diminished through change of mattresses, but also with a much more rapid handling time through the X-ray department and the Emergency department. Routines have changed so the patients will not have to return to the Acute and Emergency after X-ray. Instead they are transported directly to the orthopaedic ward. Furthermore, the patients are given a higher priority in the waiting list among the acute surgery cases. All patients are evaluated for the risk of development of pressure ulcers and those at risk get special mattresses. With these measures the development of pressure ulcers during the time in hospitals has diminished by half. Special attention is also given to the patients’ mental status. At admission to hospital one third of the patients are not lucid.

All these factors are of major importance for the rapid mobilisation of the patient in the acute ward and the continued rehabilitation.

Background: Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture but the effectiveness of nutritional support programs in routine clinical practice is controversial.

Objective: To determine if nutritional supplementation decrease fracture-related complications in a selection of otherwise healthy patients with a hip fracture.

Design: A prospective, randomised, controlled, non-placebo, non-blinded clinical trial.

Setting: A University Hospital in Sweden.

Subjects: 80 patients hospitalised for hip fracture.

Methods: We randomised patients to intervention (n=40) or control (n=40). The control group were given ordinary hospital food and beverage. The intervention group were also given 1000 kcal daily intraveneous supplementary nutrition for three days, followed by 400 kcal oral nutritional supplementation for another 7 days. Daily fluid and energy intake during the first ten days of hospitalisation and fracture-related complications at day 3, day 10, discharge, day 30 and day 120 were recorded.

Results: The total fluid and energy intake in the intervention group reached near optimal levels whereas the control group received only 54% and 64% of optimal energy and fluid intake, respectively. Six patients in the intervention group (15%) and 28 patients in the control group (70%) had at least one complication (p< 0.0001). Five patients (13%) in the control group and none in the intervention group were diagnosed with a pneumonia < 10 days from surgery (p=0.006). Twelve patients in the control group (30%) and two in the intervention group (5%) had a wound infection < 30 days from surgery (p=0.006). At day ten, a total of 16 complications in the control group and three in the intervention group had occurred (p=0.003). At one month, 33 complications in the control group and six in the intervention group were recorded (p< 0.0001). Four patients died within 120 days, all in the control group (p=0.04).

Conclusions: Nutritional supplementation given daily for 10 days after hip fracture surgery increased the total fluid and energy intake in the intervention group to near optimal levels and the intervention group displayed fewer complications than the control group.

Introduction: The treatment of hip fracture patients differs widely throughout Europe. In the SAHFE project (Standardised Audit of Hip Fractures in Europe) it was found that both waiting time to operation and mean hospitalisation time for operated patients was considerably higher in certain Mediterranean countries compared to the Northern parts of Europe. Local tradition influences both the choice of operation method and the routines for rehabilitation. Background factors were rather similar with mean age around 80 years and a predominance of female patients, 75% were women. Experiences from good examples of treatment throughout Europe are important to optimise the overall hip fracture treatment of benefits both for the individual patient and for the society in form of resources needed. The costs for hip fracture treatment are already considerable and with an ageing population the resources for treatment of these patients need to be optimised throughout the world. With more elderly in the populations, the total number of hip fracture patients is prognosticated to increase 5 times in the next 50 years. This symposium deals with means to improve the treatment results by focusing on the patient to make possible the best rehabilitation results after different operative procedures. Examples will be given from centres who have worked on the whole treatment chain for these elderly resource consuming patients.

In Scandinavia registers of locomotor system disease and trauma were developed in the mid 1970’s. In Sweden since then there exists registers of hip and knee arthroplasties and some years later similar registers were developed in Norway, Finland and Denmark. In 1988 a register on the treatment and rehabilitation of hip fractures started in Sweden and also since 1993 a spine register has been in use. The arthroplasty registers contain parameters concerning age, sex, diagnosis and technical factors for the operation. The outcome parameter is survival of the prosthesis e.g. if it has been revised or not. The real need to perform a revision arthroplasty has been considered a sufficiently well defined parameter to register. The hip fracture registration contains also background parameters as well as rehabilitation outcome including functional outcome parameters above all walking capacity and place of living. Functional outcome and patient rated quality of life are also included in the spine register. The arthroplasty registers have been very useful to separate better from not so well performing models as well as showing the importance of good cementing technique, type of cement as well as the influence of age, sex and diagnosis in a more rapid and reliable way because of the large-scale magnitude of the study. The hip fracture register has shown the importance of optimised operation and rehabilitation, which saves considerable resources in this increasing group of elderly patients. The symposium will exemplify performance, spread and results of orthopedic registers, which is an efficient way to evaluate on a large-scale everyday orthopedic practise. This way of registration has attracted great interest and is now spreading internationally. For hip fractures a European project has started called SAHFE (Standardised Audit of Hip Fractures in Europe).

Hip fractures have increased in most western countries during the end of the last century. This increase will continue mainly because of an increasing number of elderly persons and also due to an increase in the risk of hip fractures in the oldest. This constitutes a threat to resources for medical care. Practise differs concerning choice of operation method and principles for rehabilitation throughout the world. A national registration of the outcome after hip fractures in the elderly started in 1988 in Sweden to compare different methods of surgery, mobilization and rehabilitation. This project has attracted great international interest and several centres have participated with prospective registration. With support from the European Commission a project was started in 1995 called Standardised Audit of Hip Fracture in Europe (SAHFE). The project aims to encourage centres in Europe to participate in a hip fracture audit with a defined data set consisting of a core of 34 questions which includes outcome measures at 4 months from operation. Printed forms are distributed to the participants as well as a computer program designed for the project. In addition there is a large number of optional questions. Each participating centres collects its own data and registers for own analysis. The data are then sent to the project centre in Lund. Hospitals wishing to participate in these international comparisons are welcome. The SAHFE project will promote comparisons of demographic features, surgical technique and rehabilitation methods to facilitate the dissemination of the best practise of hip fracture surgery and rehabilitation throughout Europe. Further international participation will widen the spectrum and facilitate improvements of the hip fracture treatment of benefit both to the patients and the society which has to provide health care to the increasing number of elderly.

Aims: To find out if osteosynthesis (OS) or hemiarthroplasty (HA) is better in terms of functional outcome. Patients and methods: In 1989–1996, all displaced cervical hip fractures were prospectively, using the same forms, registered at the University Hospitals of Oulu in Finland and Lund in Sweden. Cross-matchings was performed for age, sex, preoperative residence, and ambulatory capacity. Results: The first study comprised 357 pairs (OS with two hook pins and cementless Austin-Moore HA): OS was associated with a better functional outcome and lower mortality, but a higher re-operation rate than hemiarthroplasty. The second study had 446 pairs (OS two hook pins and cemntless HA): OS was associated with better function and lower mortality than HA, especially in younger patients, and it is recommended as the primary treatment for cervical non-pathological hip fractures in patients younger than 80 years and with good ambulatory capacity, whereas the oldest patients can also be safely treated by HA. The third study comprised 82 pairs (OS with three screws and cementless HA): Functional recovery is slightly better after OS with three screws than after uncemented HA, although no significant differences were seen in a sample of this size. On the other hand, OS is associated with a higher re-operation rate. Conclusion: OS seemed somewhat better in terms of functional outcome.

In a prospective, randomised trial, we compared the use of three Ullevaal hip screws with that of two Hansson hook-pins in 278 patients with fractures of the femoral neck. Background factors were similar in both groups. Follow-up was for two years.

There were no significant differences between the groups in length of time of surgery, hospital stay, general complications, mortality, pain or walking ability. Likewise, the rates of early failure of fixation, nonunion, and the need for reoperation did not differ significantly between the groups. The use of hook-pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6, p= 0.05) and a lower incidence of necrosis of the femoral head (odds ratio 3.5, p = 0.04). There was a strong relationship between poor reduction and fixation of the fracture and subsequent reoperation (p = 0.0005 and p = 0.0001, respectively). Likewise, peroperative drill penetration of the femoral head was associated with a greater risk of reoperation (p = 0.038). Both methods gave favourable results. In total, 22% of the patients needed a major reoperation (usually hemiarthroplasty), while in 7% of the cases the fixation device needed to be removed. Osteosynthesis as the sole method for operation of all fractures of the femoral neck was thus successful in 78% of patients. With selective treatment most of the remaining patients would have benefited if treated by a primary arthroplasty. Accurate selection requires the development of better prognostic methods.

Sterilisation of demineralised bone matrix with ethylene oxide has been claimed to destroy the ability of bone matrix to induce new bone formation on intramuscular implantation. Other workers have routinely used ethylene oxide sterilised bone matrix for assays in rodents without detrimental effects. We studied the effects of various lengths of exposure to ethylene oxide gas, and found that bone induction properties are destroyed in a dose-dependent manner. After a short exposure, bone induction properties were moderately diminished. However, this short ethylene oxide treatment did not kill Bacillus subtilis spores. A sterilisation procedure that killed these spores rendered the implants incapable of bone-induction.

We report a series of 640 consecutive cervical hip fractures which were followed prospectively for two years after primary internal fixation with two hook-pins. Secondary arthroplasties were performed as salvage procedures in 75 cases and the early outcome of these was studied retrospectively. The mean time in hospital was 25 days for prosthetic replacement, though 60% of the patients had other medical conditions considered as risk factors. Mortality was 5% after six months and 8% after one year. Dislocation was seen in 11% and additional surgery was required in 4%. There was one case of deep infection and one supracondylar femoral fracture. In some cases there was considerable delay between the primary and secondary operation due to lack of awareness of functional deterioration, but although many patients had poor mobility before the secondary operation this was greatly improved within six weeks of the arthroplasty. We conclude that elective secondary hip arthroplasty for failure of fracture fixation is a safe and successful procedure. Once the decision to perform an arthroplasty is taken, this should be done without delay to avoid deterioration of function.

Extraskeletal bone formation can be induced in rodents by implantation of demineralised bone matrix and such implantation has been used to treat bone defects in man, but it is uncertain if induction or merely conduction occurs. We studied bone induction in primates by excising segments of the fibulae of adult squirrel monkeys, defatting and demineralising them before reimplanting them into the quadriceps of the same animal. As a control experiment, rat matrix was prepared in exactly the same way and implanted in rats. After six weeks the implants were harvested and either ashed and analysed for calcium content or prepared for histology. In the rats, the calcium content indicated that about 20% of the original matrix had been replaced by new bone. In the monkeys the calcium content was about the same as that in normal body fluid and no bone was seen in histological sections. This result casts doubt on the use of demineralised human bone matrix as a bone inductor, although it may function by other mechanisms.

We studied intracapsular pressure in 50 patients with Garden Grade I and II subcapital fractures. Before operation pressures varied from zero to 320 mmHg, 16 patients having an intracapsular pressure of over 80 mmHg. The pressure was increased considerably by medial rotation and decreased by lateral rotation and especially by semi-flexion. From zero to 36 ml of blood was aspirated; the amount did not correlate with the intracapsular pressure. Of 25 patients who were also examined by scintimetry, 13 had reduced uptake at the femoral head before aspiration, and nine of these showed a marked increase in uptake after aspiration. Intracapsular tamponade of the hip may be one reason for the occasional occurrence of segmental collapse of the femoral head after subcapital fracture with minor displacement.