Aims. Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures. Methods. We interrogated the NHFD data on patients presenting with hip fractures to our institution from 2016 to 2018. POD was determined using the 4AT score, as recommended by the NHFD and UK Department of Health. POCD was defined as a decline in Abbreviated Mental Test Score (AMTS) of two or greater. Using logistic regression, we adjusted for covariates to identify factors associated with POD and POCD. Results. Of the 1,224 patients presenting in the study period, 1,023 had complete datasets for final analysis. POD was observed in 242 patients (25%). On multivariate analysis only preoperative AMTS and American Society of Anesthesiologists grade (ASA) were independent predictors of POD. Every point increase in AMTS was associated with a fall in the odds of POD by a factor of 0.60 (95% confidence interval (CI) 0.56 to 0.63, p < 0.001). Every grade increase in ASA led to a 1.7-fold increase in the odds of POD (95% CI 1.13 to 2.50, p = 0.009). A preoperative AMTS of less than 8 was strongly predictive of POD with area under the receiver operating characteristic of 0.86 (95% CI 0.84 to 0.89). Only ASA was predictive of POCD—every grade increase in ASA led to a 2.6-fold increase in the odds of POCD (95% CI 1.7 to 4.0, p < 0.001). Conclusion. POD and POCD are common in the hip fracture patients. Preoperative AMTS and ASA are strong predictors of POD, and ASA predictive of POCD. This may aid in the earlier identification of those most at risk and suited for the patient consent and decision-making process. Cite this article: Bone Joint J 2020;102-B(12):1675–1681

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. 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

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

Aims

Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty.

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.

Aims

Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

Aims

This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year.

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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.

Aims

There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

Aims

To assess the variation in pre-fracture quality of life (QoL) within the UK hip fracture population, and quantify the nature and strength of associations between QoL and other routinely collected patient characteristics and treatment choices.

Aims

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery.

Aims

Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution.

Aims

This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK.

Aim

This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial.

This review summarises the evidence for the treatment of displaced fractures of the femoral neck in elderly patients. Results from randomised clinical trials and national register studies are presented when available.

The advantages of arthroplasty compared with internal fixation are supported by several studies. A number of studies contribute to the discussions of total hip arthroplasty (THA) versus hemiarthroplasty and unipolar versus bipolar hemiarthroplasty, but no clear-cut evidence-based recommendation can be made. THA may be particularly advantageous for active, lucid patients with a relatively long life expectancy. For patients who are physiologically older, hemiarthoplasty is probably satisfactory, and for the oldest patients with more comorbidities, unipolar implants are considered to be sufficient. If the hospital can support emergency THA surgery in sufficient numbers and quality, there may be few patients who warrant bipolar hemiarthroplasty.

The direct lateral approach reduces the risk of dislocation compared with the posterior approach. Cemented implants lower the risk of periprosthetic fracture and its subsequent morbidity and mortality. As the risk of peri-operative death related to bone cement can be reduced by adequate measures, cemented implants are recommended in fracture cases.

Take home message: There remains a great variation in the surgical management of patients with a hip fracture, and an evidence-based approach should improve the outcomes for this vulnerable patient group.

Cite this article: Bone Joint J 2016;98-B:291–7.

Objectives

Fractures of the proximal femur are a common clinical problem, and a number of orthopaedic devices are available for the treatment of such fractures. The objective of this study was to assess the rotational stability, a common failure predictor, of three different rotational control design philosophies: a screw, a helical blade and a deployable crucifix.

Objectives

The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?

Aims

The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck.

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

The lack of a consensus for core health outcomes that should be reported in clinical research has hampered study design and evidence synthesis. We report a United Kingdom consensus for a core outcome set (COS) for clinical trials of patients with a hip fracture.

We adopted a modified nominal group technique to derive consensus on 1) which outcome domains should be measured, and 2) methods of assessment. Participants reflected a diversity of perspectives and experience. They received an evidence synthesis and postal questionnaire in advance of the consensus meeting, and ranked the importance of candidate domains and the relevance and suitability of short-listed measures. During the meeting, pre-meeting source data and questionnaire responses were summarised, followed by facilitated discussion and a final plenary session. A COS was determined using a closed voting system: a 70% consensus was required.

Consensus supported a five-domain COS: mortality, pain, activities of daily living, mobility, and health-related quality of life (HRQL). Single-item measures of mortality and mobility (indoor/outdoor walking status) and a generic multi-item measure of HRQL - the EuroQoL EQ-5D - were recommended. These measures should be included as a minimum in all hip fracture trials. Other outcome measures should be added depending on the particular interventions being studied.

Cite this article: Bone Joint J 2014; 96-B:1016–23.

We compared the clinical and radiological outcomes of two cementless femoral stems in the treatment of patients with a Garden III or IV fracture of the femoral neck. A total of 70 patients (70 hips) in each group were enrolled into a prospective randomised study. One group received a short anatomical cementless stem and the other received a conventional cementless stem. Their mean age was 74.9 years (50 to 94) and 76.0 years (55 to 96), respectively (p = 0.328). The mean follow-up was 4.1 years (2 to 5) and 4.8 years (2 to 6), respectively. Perfusion lung scans and high resolution chest CTs were performed to detect pulmonary microemboli.

At final follow-up there were no statistically significant differences between the short anatomical and the conventional stems with regard to the mean Harris hip score (85.7 (66 to 100) versus 86.5 (55 to 100); p = 0.791), the mean Western Ontario and McMaster Universities Osteoarthritis Index (17 (6 to 34) versus 16 (5 to 35); p = 0.13) or the mean University of California, Los Angeles activity score (5 (3 to 6) versus 4 (3 to 6); p = 0.032). No patient with a short stem had thigh pain, but 11 patients (16%) with a conventional stem had thigh pain. No patients with a short stem had symptomatic pulmonary microemboli, but 11 patients with a conventional stem had pulmonary microemboli (symptomatic in three patients and asymptomatic in eight patients). One hip (1.4%) in the short stem group and eight (11.4%) in the conventional group had an intra-operative undisplaced fracture of the calcar. No component was revised for aseptic loosening in either group. One acetabular component in the short stem group and two acetabular components in the conventional stem group were revised for recurrent dislocation.

Our study demonstrated that despite the poor bone quality in these elderly patients with a fracture of the femoral neck, osseo-integration was obtained in all hips in both groups. However, the incidence of thigh pain, pulmonary microemboli and peri-prosthetic fracture was significantly higher in the conventional stem group than in the short stem group.