Aims. Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined. Methods. This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality. Results. The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance. Conclusion. In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article: Bone Joint J 2021;103-B(4):782–787

Aims. To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods. A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1). Results. We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion. A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments. Cite this article: Bone Jt Open 2024;5(6):524–531

Aims. The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks. Methods. Data were collected retrospectively on 157 hip fractures admitted from March to May 2019 and 2020. The 2020 group was further subdivided into COVID-positive and COVID-negative. Data including the four-hour target, timing to imaging, hours to operation, anaesthetic and operative details, intraoperative complications, postoperative reviews, COVID status, Key Performance Indicators (KPIs), length of stay, postoperative complications, and the 30-day mortality were compiled from computer records and our local National Hip Fracture Database (NHFD) export data. Results. Hip fractures and inpatient falls significantly increased by 61.7% and 7.2% respectively in the 2020 group. A significant difference was found among the three groups regarding anaesthetic preparation time, anaesthetic time, and recovery time. The mortality rate in the 2020 COVID-positive group (36.8%) was significantly higher than both the 2020 COVID-negative and 2019 groups (11.5% and 11.7% respectively). The hospital stay was significantly higher in the COVID-positive group (mean of 24.21 days (SD 19.29)). Conclusion. COVID-19 has had notable effects on the hip fracture care service: hip fracture rates increased significantly. There were inefficiencies in theatre processes for which we have recommended the use of alternate theatres. COVID-19 infection increased the 30-day mortality and hospital stay in hip fractures. More research needs to be done to reduce this risk. Cite this article: Bone Joint Open 2020;1-9:530–540

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

Aims. Hip fracture patients have high morbidity and mortality. Patient-reported outcome measures (PROMs) assess the quality of care of patients with hip fracture, including those with chronic cognitive impairment (CCI). Our aim was to compare PROMs from hip fracture patients with and without CCI, using the Norwegian Hip Fracture Register (NHFR). Methods. PROM questionnaires at four months (n = 34,675) and 12 months (n = 24,510) after a hip fracture reported from 2005 to 2018 were analyzed. Pre-injury score was reported in the four-month questionnaire. The questionnaires included the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, and information about who completed the questionnaire. Results. Of the 34,675 included patients, 5,643 (16%) had CCI. Patients with CCI were older (85 years vs 81 years) (p < 0.001), and had a higher American Society of Anesthesiologists (ASA) classification compared to patients without CCI. CCI was unrelated to fracture type and treatment method. EQ-5D index scores were lower in patients with CCI after four months (0.37 vs 0.60; p < 0.001) and 12 months (0.39 vs 0.64; p < 0.001). Patients with CCI had lower scores for all dimensions of the EQ-5D-3L pre-fracture and at four and 12 months. Conclusion. Patients with CCI reported lower health-related quality of life pre-fracture, at four and 12 months after the hip fracture. PROM data from hip fracture patients with CCI are valuable in the assessment of treatment. Patients with CCI should be included in future studies. Cite this article: Bone Jt Open 2021;2(7):454–465

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. Methods. A systematic literature search was conducted in August 2022. ONS was defined as high protein-based diet strategies containing (or not containing) carbohydrates, fat, vitamins, and minerals. Randomized trials documenting ONS in older patients with hip fracture (aged ≥ 50 years) were included. Two reviewers evaluated study eligibility, conducted data extraction, and assessed study quality. Results. There were 812 studies identified, of which 18 studies involving 1,522 patients met the inclusion criteria. The overall meta-analysis demonstrated that ONS was associated with significantly elevated albumin levels (weighted mean difference (WMD) 1.24 (95% confidence interval (CI) 0.95 to 1.53)), as well as a significant risk reduction in infective complications (odds ratio (OR) 0.54 (95% CI 0.39 to 0.76)), pressure ulcers (OR 0.54 (95% CI 0.33 to 0.88)), and total complications (OR 0.57 (95% CI 0.42 to 0.79)). Length of hospital stay (LOS) was also significantly reduced (WMD -2.36 (95% CI -4.14 to -0.58)), particularly in rehabilitation LOS (WMD -4.17 (95% CI -7.08 to -1.26)). There was a tendency towards a lower mortality risk (OR 0.93 (95% CI 0.62 to 1.4)) and readmission (OR 0.52 (95% CI 0.16 to 1.73)), although statistical significance was not achieved (p = 0.741 and p = 0.285, respectively). The overall compliance with ONS ranged from 64.7% to 100%, but no factors influencing compliance were identified. Conclusion. This meta-analysis is the first to quantitatively demonstrate that ONS could nearly halve the risk of infective complications, pressure ulcers, total complications, as well as improve serum albumin and reduce LOS. ONS should be a regular and integrated part of the perioperative care of these patients, especially given that the compliance with ONS is acceptable. Cite this article: Bone Joint J 2023;105-B(11):1149–1158

Aims. We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture. Methods. Of 1,577 consecutive patients aged > 65 years with a fragility hip fracture admitted to one institution, for whom there were complete data, 1,255 (72%) were studied. Clinicians assigned CFS scores on admission. Audit personnel routinely prospectively completed the Standardised Audit of Hip Fracture in Europe form, including the following outcomes: 30-day survival; in-hospital complications; length of acute hospital stay; and new institutionalization. The relationship between the CFS scores and outcomes was examined graphically and the visual interpretations were tested statistically. The predictive values of the CFS and Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality were compared using receiver operating characteristic area under the curve (AUC) analysis. Results. Significant non-linear associations between CFS and outcomes were observed. Risk of death within 30 days rose linearly for CFS 1 to 5, but plateaued for CFS > 5. The incidence of complications and length of stay rose linearly for CFS 1 to 4, but plateaued for CFS > 4. In contrast, the risk of new institutionalization rose linearly for CFS 1 to 8. The AUCs for 30-day mortality for the CFS and NHFS were very similar: CFS AUC 0.63 (95% CI 0.57 to 0.69) and NHFS AUC 0.63 (95% CI 0.57 to 0.69). Conclusion. Use of the CFS may provide useful information on outcomes for fitter patients presenting with hip fracture, but completion of the CFS by the admitting orthopaedic team does not appear successful in distinguishing between higher CFS categories, which define patients with frailty. This makes a strong case for the role of the orthogeriatrician in the early assessment of these patients. Further work is needed to understand why patients assessed as being of mild, moderate, and severe frailty do not result in different outcomes. Cite this article: Bone Joint J 2022;104-B(8):980–986

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 primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission. Methods. A nationwide multicentre retrospective cohort study was conducted of all patients presenting with a hip fracture to 17 Scottish centres in March and April 2020. Demographics, presentation blood tests, COVID-19 status, Nottingham Hip Fracture Score, management, length of stay, and 30-day mortality were recorded. Results. In all, 78/833 (9.4%) patients were diagnosed with COVID-19. The 30-day survival of patients with COVID-19 was significantly lower than for those without (65.4% vs 91%; p < 0.001). Diagnosis of COVID-19 within seven days of admission (likely community acquired) was independently associated with male sex (odds ratio (OR) 2.34, p = 0.040, confidence interval (CI) 1.04 to 5.25) and symptoms of COVID-19 (OR 15.56, CI 6.61 to 36.60, p < 0.001). Diagnosis of COVID-19 made between seven and 30 days of admission to hospital (likely hospital acquired) was independently associated with male sex (OR 1.73, CI 1.05 to 2.87, p = 0.032), Nottingham Hip Fracture Score ≥ 7 (OR 1.91, CI 1.09 to 3.34, p = 0.024), pulmonary disease (OR 1.68, CI 1.00 to 2.81, p = 0.049), American Society of Anesthesiologists (ASA) grade ≥ 3 (OR 2.37, CI 1.13 to 4.97, p = 0.022), and length of stay ≥ nine days (OR 1.98, CI 1.18 to 3.31, p = 0.009). A total of 38 (58.5%) COVID-19 cases were probably hospital acquired infections. The false-negative rate of a negative swab on admission was 0% in asymptomatic patients and 2.9% in symptomatic patients. Conclusion. COVID-19 was independently associated with a three times increased 30-day mortality rate. Nosocomial transmission may have accounted for approximately half of all cases during the first wave of the pandemic. Identification of risk factors for having COVID-19 on admission or acquiring COVID-19 in hospital may guide pathways for isolating or shielding patients respectively. Length of stay was the only modifiable risk factor, which emphasizes the importance of high-quality and timely care in this patient group. Cite this article: Bone Joint J 2021;103-B(5):888–897

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. The aim of this study was to determine whether national standards of best practice are associated with improved health-related quality of life (HRQoL) outcomes in hip fracture patients. Methods. This was a multicentre cohort study conducted in 20 acute UK NHS hospitals treating hip fracture patients. Patients aged ≥ 60 years treated operatively for a hip fracture were eligible for inclusion. Regression models were fitted to each of the “Best Practice Tariff” indicators and overall attainment. The impact of attainment on HRQoL was assessed by quantifying improvement in EuroQol five-dimension five-level questionnaire (EQ-5D-5L) from estimated regression model coefficients. Results. A total of 6,532 patients provided both baseline and four-month EQ-5D-5L, of whom 1,060 participants had died at follow-up. Best practice was achieved in the care of 57% of participants; there was no difference in age, cognitive ability, and mobility at baseline for the overall attainment and non-attainment groups. Attaining at least ‘joint care by surgeon and orthogeriatrician’, ‘delirium assessment’, and ‘falls assessment’ was associated with a large, clinically relevant increase in four months EQ-5D-5L of 0.094 (bootstrapped 95% confidence interval (CI) 0.046 to 0.146). Conclusion. National standards with enhanced remuneration in hip fracture care results in improvement in individual patients’ HRQoL. Cite this article: Bone Joint J 2021;103-B(5):881–887

Aims. Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. Methods. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality). Results. A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA. Conclusion. Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222–233

Aims. Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures. Methods. We reviewed our prospectively maintained trust database and National Hip Fracture Database records for the months of March and April between the years 2016 and 2020. Our assessment included fracture pattern (intrascapular vs extracapsular hip fracture), treatment intervention, length of stay and mortality. Results. We treated 288 patients during March and April between 2016 and 2020, with a breakdown of 55, 58, 53, 68, and 54 from 2016 to 2020 respectively. Fracture pattern distribution in the pre-COVID-19 years of 2016 to 2019 was 58% intracapsular and 42% extracapsular. In 2020 (COVID-19 period) the fracture patterns were 65% intracapsular and 35% extracapsular. Our mean length of stay was 13.1 days (SD 8.2) between 2016 to 2019, and 5.0 days (6.3) days in 2020 (p < 0.001). Between 2016 and 2019 we had three deaths in hip fracture patients, and one death in 2020. Hemiarthroplasty and dynamic hip screw fixation have been the mainstay of operative intervention across the five years and this has continued in the COVID-19 period. We have experienced a rise in conservatively managed patients; ten in 2020 compared to 14 over the previous four years. Conclusion. There has not been a reduction in the number of hip fractures during COVID-19 period compared to the same time period over previous years. In our experience, there has been an increase in conservative treatment and decreased length of stay during the COVID -19 period. Cite this article: Bone Joint Open 2020;1-8:500–507

Aims. Hip fracture is a common condition of the older, frailer person. This population is also at risk from SARS-CoV-2 infection. It is important to understand the impact of coexistent hip fracture and SARS-CoV-2 for informed decision-making at patient and service levels. Methods. We undertook a systematic review and meta-analysis of observational studies of older (> 60 years) people with fragility hip fractures and outcomes with and without SARS-CoV-2 infection during the first wave of the COVID-19 pandemic. The primary outcome was early (30-day or in-hospital) mortality. Secondary outcomes included length of hospital stay and key clinical characteristics known to be associated with outcomes after hip fracture. Results. A total of 14 cohort and five case series studies were included (692 SARS-CoV-2 positive, 2,585 SARS-CoV-2 negative). SARS-CoV-2 infection was associated with an overall risk ratio (RR) for early mortality of 4.42 (95% confidence interval (CI) 3.42 to 5.82). Early mortality was 34% (95% CI 30% to 38%) and 9% (95% CI 8% to 10%) in the infected and noninfected groups respectively. Length of stay was increased in SARS-CoV-2 infected patients (mean difference (MD) 5.2 days (3.2 to 7.2)). Age (MD 1.6 years (0.3 to 2.9)); female sex (RR 0.83 (95% CI 0.65 to 1.05)); admission from home (RR 0.51 (95% CI 0.26 to 1.00)); presence of dementia (RR 1.13 (95% CI 0.94 to 1.43)); and intracapsular fracture (RR 0.89 (95% CI 0.71 to 1.11)) were not associated with SARS-CoV-2 infection. There were statistically, but not clinically, significantly greater Nottingham Hip Fracture Scores in infected compared with non-infected patients (MD 0.7 (0.4 to 0.9)). Conclusion. SARS-CoV-2 infection is associated with worse outcomes after hip fracture. This is not explained by differences in patient characteristics. These data can be used to support informed decision-making and may help track the impact of widespread adoption of system-level and therapeutic changes in management of the COVID-19 pandemic. Cite this article: Bone Jt Open 2021;2(5):314–322

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. Type 2 diabetes mellitus (T2DM) impairs bone strength and is a significant risk factor for hip fracture, yet currently there is no reliable tool to assess this risk. Most risk stratification methods rely on bone mineral density, which is not impaired by diabetes, rendering current tests ineffective. CT-based finite element analysis (CTFEA) calculates the mechanical response of bone to load and uses the yield strain, which is reduced in T2DM patients, to measure bone strength. The purpose of this feasibility study was to examine whether CTFEA could be used to assess the hip fracture risk for T2DM patients. Methods. A retrospective cohort study was undertaken using autonomous CTFEA performed on existing abdominal or pelvic CT data comparing two groups of T2DM patients: a study group of 27 patients who had sustained a hip fracture within the year following the CT scan and a control group of 24 patients who did not have a hip fracture within one year. The main outcome of the CTFEA is a novel measure of hip bone strength termed the Hip Strength Score (HSS). Results. The HSS was significantly lower in the study group (1.76 (SD 0.46)) than in the control group (2.31 (SD 0.74); p = 0.002). A multivariate model showed the odds of having a hip fracture were 17 times greater in patients who had an HSS ≤ 2.2. The CTFEA has a sensitivity of 89%, a specificity of 76%, and an area under the curve of 0.90. Conclusion. This preliminary study demonstrates the feasibility of using a CTFEA-based bone strength parameter to assess hip fracture risk in a population of T2DM patients. Cite this article: Bone Joint J 2021;103-B(9):1497–1504

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. To assess the safety of tranexamic acid (TXA) in a large cohort of patients aged over 65 years who have sustained a hip fracture, with a focus on transfusion rates, mortality, and thromboembolic events. Methods. This is a consecutive cohort study with prospectively collected registry data. Patients with a hip fracture in the Region of Southern Denmark were included over a two-year time period (2015 to 2017) with the first year constituting a control group. In the second year, perioperative TXA was introduced as an intervention. Outcome was transfusion frequency, 30-day and 90-day mortality, and thromboembolic events. The latter was defined as any diagnosis or death due to arterial or venous thrombosis. The results are presented as relative risk (RR) and hazard ratio (HR) with 95% confidence intervals (CIs). Results. A total of 3,097 patients were included: 1,558 in the control group and 1,539 in the TXA group.31% (n = 477) of patients had transfusions in the control group compared to 27% (n = 405) in the TXA group yielding an adjusted RR of 0.83 (95% CI 0.75 to 0.91). TXA was not associated with increased 30-day mortality with an adjusted HR of 1.10 (95% CI 0.88 to 1.39) compared to the control group as well as no association with increased risk of 90-day mortality with a per protocol adjusted HR of 1.24 (95% CI 0.93 to 1.66). TXA was associated with a lower risk of thromboembolic events after 30 days (RR 0.63 (95% CI 0.42 to 0.93)) and 90 days (RR 0.72 (95% CI 0.52 to 0.99)). A subanalysis on haemoglobin demonstrated a median 17.7 g/L (interquartile range (IQR) 11.3 to 27.3) decrease in the control group compared to 17.7 g/L (IQR 9.7 to 25.8) in the per protocol TXA group (p = 0.060 on group level difference). Conclusion. TXA use in patients with a hip fracture, was not associated with an increased risk of mortality but was associated with lower transfusion rate and reduced thromboembolic events. Thus, we conclude that it is safe to use TXA in this patient group. Cite this article: Bone Joint J 2021;103-B(3):449–455

Aims. Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms. Methods. A population-based, matched cohort study of all hip fracture patients (aged over 45 years) in Ontario, Canada between 2009 and 2014 was conducted. The primary exposure was preoperative echocardiography (occurring between hospital admission and surgery). Mortality rates, surgical wait times, postoperative LOS, and medical costs (expressed as 2013$ CAN) up to one year postoperatively were assessed after propensity-score matching. Results. A total of 2,354 of 42,230 (5.6%) eligible hip fracture patients received a preoperative echocardiogram during the study period. Echocardiography ordering practices varied among hospitals, ranging from 0% to 23.0% of hip fracture patients at different hospital sites. After successfully matching 2,298 (97.6%) patients, echocardiography was associated with significantly increased risks of mortality at 90 days (20.1% vs 16.8%; p = 0.004) and one year (32.9% vs 27.8%; p < 0.001), but not at 30 days (11.4% vs 9.8%; p = 0.084). Patients with echocardiography also had a mean increased delay from presentation to surgery (68.80 hours (SD 44.23) vs 39.69 hours (SD 27.09); p < 0.001), total LOS (19.49 days (SD 25.39) vs 15.94 days (SD 22.48); p < 0.001), and total healthcare costs at one year ($51,714.69 (SD 54,675.28) vs $41,861.47 (SD 50,854.12); p < 0.001). Conclusion. Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality at 90 days and one year but not at 30 days. Preoperative echocardiography is also associated with increased surgical delay, postoperative LOS, and total healthcare costs at one year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay. Cite this article: Bone Joint J 2021;103-B(2):271–278

The June 2023 Trauma Roundup. 360. looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures