Use of medical comorbidities to predict complications after hip fracture surgery in the elderly

[Early complication rate of fractures close to the hip joint. Dependence on treatment in on-call services and comorbidities]

BACKGROUND

Guidelines advocate early surgery for proximal femoral fractures so that operations are frequently performed in on-call duty times. Multimorbid patients also suffer more frequently from postoperative complications. Does on-call duty or night shift services correlate with higher postoperative complication rates and what influence do comorbidities have?

PATIENTS AND METHODS

In 300 patients (> 65 years) postoperative surgical and non-surgical complications were documented and correlated with comorbidities, on-call duty and night shift service times.

RESULTS

Postoperative complications were observed in 10.7 % of surgical and 62 % of non-surgical cases. Surgery in on-call duty and night shift times did not increase the postoperative complication rate. Comorbidities, age and ASA classification correlated with postoperative complications which significantly prolonged hospital stay.

CONCLUSION

Surgery of proximal femoral fractures in on-call duty and night shift times is justified because postoperative complications are not increased. Comorbidities and higher age correlated with postoperative complications. Postoperative complications should be avoided because they result in prolonged hospital stay.

Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

BACKGROUND

Osteoporotic hip fractures are common injuries typically occurring in patients who are older and medically frail. Studies have suggested that creation of a multidisciplinary team including orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists, to comanage these patients can decrease complication rates, improve time to surgery, and reduce hospital length of stay; however, they have yet to achieve widespread implementation, partly owing to concerns regarding resource requirements necessary for a comanagement program.

QUESTIONS/PURPOSES

We performed an economic analysis to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be a cost-effective intervention at hospitals with moderate volume. We also calculated what annual volume of cases would be needed for a comanagement program to "break even", and finally we evaluated whether universal or risk-stratified comanagement was more cost effective.

METHODS

Decision analysis techniques were used to model the effect of implementing a systems-based strategy to improve inpatient perioperative care. Costs were obtained from best-available literature and included salary to support personnel and resources to expedite time to the operating room. The major economic benefit was decreased initial hospital length of stay, which was determined via literature review and meta-analysis, and a health benefit was improvement in perioperative mortality owing to expedited preoperative evaluation based on previously conducted meta-analyses. A break-even analysis was conducted to determine the annual case volume necessary for comanagement to be either (1) cost effective (improve health-related quality of life enough to be worth additional expenses) or (2) result in cost savings (actually result in decreased total expenses). This calculation assumed the scenario in which a hospital could hire only one hospitalist (and therapist and social worker) on a full-time basis. Additionally, we evaluated the scenario where the necessary staff was already employed at the hospital and could be dedicated to a comanagement service on a part-time basis, and explored the effect of triaging only patients considered high risk to a comanagement service versus comanaging all geriatric patients. Finally, probabilistic sensitivity analysis was conducted on all critical variables, with broad ranges used for values around which there was higher uncertainty.

RESULTS

For the base case, universal comanagement was more cost effective than traditional care and risk-stratified comanagement (incremental cost effectiveness ratios of USD 41,100 per quality-adjusted life-year and USD 81,900 per quality-adjusted life-year, respectively). Comanagement was more cost effective than traditional management as long as the case volume was more than 54 patients annually (range, 41-68 patients based on sensitivity analysis) and resulted in cost savings when there were more than 318 patients annually (range, 238-397 patients). In a scenario where staff could be partially dedicated to a comanagement service, universal comanagement was more cost effective than risk-stratified comanagement (incremental cost effectiveness of USD 2300 per quality-adjusted life-year), and both comanagement programs had lower costs and better outcomes compared with traditional management. Sensitivity analysis was conducted and showed that the level of uncertainty in key variables was not high enough to change the core conclusions of the model.

CONCLUSIONS

Implementation of a systems-based comanagement strategy using a dedicated team to improve perioperative medical care and expedite preoperative evaluation is cost effective in hospitals with moderate volume and can result in cost savings at higher-volume centers. The optimum patient population for a comanagement strategy is still being defined.

LEVEL OF EVIDENCE

Level 1, Economic and Decision Analysis.

Impact of Parkinson's disease on the acute care treatment and medium-term functional outcome in geriatric hip fracture patients

INTRODUCTION

Patients with Parkinson's disease (PD) have a heightened risk of sustaining hip fractures due to disturbed balance and gait insecurity. This study aims to determine the impact of PD on the perioperative course and medium-term functional outcome of patients with hip fractures.

MATERIALS AND METHODS

A total of 402 hip fracture patients, aged ≥60 years, were prospectively enrolled. On admission, the American Society of Anesthesiologists score, Mini-Mental Status Examination, and Barthel Index (BI), among other scales, were documented. The Hoehn and Yahr scale was used to assess the severity of PD. The functional outcome was assessed by performance on the BI, Tinetti test (TT), and Timed Up and Go test (TUG) at discharge and at the 6-month follow-up. Additionally, the length of hospitalization, perioperative complications, and discharge management were documented. A multivariate regression analysis was performed to control for influencing factors.

RESULTS

A total of 19 patients (4.7%) had a concomitant diagnosis of PD. The functional outcome (BI, TT, and TUG) was comparable between groups (all p > 0.05). Grade II (52.6 vs. 26.1%; OR = 4.304, p = 0.008) and IV complications (15.8 vs. 4.4%; OR = 7.785, p = 0.012) occurred significantly more often among PD patients. While the diagnosis of PD was associated with a significantly longer mean length of hospital stay (β = 0.119, p = 0.024), the transfer from acute hospital care showed no significant difference (p = 0.246). Patients with an additional diagnosis of PD had inferior results in BI at the 6-month follow-up (p = 0.038).

CONCLUSION

PD on hospital admission is not an independent risk factor for in-hospital mortality or an inferior functional outcome at hospital discharge. However, patients with PD are at risk for specific complications and longer hospitalization at the time of transfer from acute care so as for reduced abilities in activities of daily living in the medium term.

Implementing the Surgical Apgar Score in patients with trauma hip fracture

BACKGROUND

Trauma hip fractures in elderly patients are associated with high postoperative long-term morbidity and mortality and premature death. The high mortality in these patients can be explained by various factors, including the fracture itself; the preoperative poor condition and comorbidities of these patients; the influence of stressors, such as surgery and type of anaesthesia, on the patient's condition; and the postoperative development of major complications, such as cardiac failure, pulmonary embolism, pneumonia, deep venous thrombosis and acute renal failure. Thus, the Surgical Apgar Score (SAS) could be a valuable tool for objective risk stratification of patients immediately after surgery, and to enable patients with higher risk to receive postoperative ICU care and good management both during and after the hospital stay.

METHODS

The SAS was calculated retrospectively from the handwritten anaesthesia records of 43 trauma hip fracture patients treated operatively in the University Hospital Centre Zagreb over a 1-year period. The primary endpoints were the 30-days major postoperative complications and mortality, length of the ICU and hospital stay, and 6-months major complications development. Statistical analysis was applied to compare SAS with the patients' perioperative variables.

RESULTS

A SAS≤4 in the trauma hip fracture patients was a significant predictor for the 30-days major postoperative complications with 80% specificity (95% CI: 0.587-0.864, p=0.0111). However, the SAS was not significant in the prediction of 30-days mortality (95% CI: 0.468-0.771, p=0.2238) and 6-months mortality (95% CI: 0.497-0.795, p=0.3997) as primary endpoints in the hip fracture surgery patients.

CONCLUSION

The SAS shows how intraoperative events affect postoperative outcomes. Calculating the SAS in the operating theatre provides immediate, reliable, real-time feedback information about patient postoperative risk. The results of this study indicate that all trauma hip fracture patients with SAS≤4 should go to the ICU postoperatively and should be under intensive surveillance both during the hospital stay and after hospital discharge.

[Results following the implementation of a clinical pathway in the process of care to elderly patients with osteoporotic hip fracture in a second level hospital]

PURPOSE

To evaluate the efficiency of a clinical pathway in the management of elderly patients with fragility hip fracture in a second level hospital in terms of length of stay time to surgery, morbidity, hospital mortality, and improved functional outcome.

MATERIAL AND METHODS

A comparative and prospective study was carried out between two groups of patients with hip fracture aged 75 and older prior to 2010 (n=216), and after a quality improvement intervention in 2013 (n=196). A clinical pathway based on recent scientific evidence was implemented. The degree of compliance with the implemented measures was quantified.

RESULTS

The characteristics of the patients in both groups were similar in age, gender, functional status (Barthel Index) and comorbidity (Charlson Index). Median length of stay was reduced by more than 45% in 2013 (16.61 vs. 9.08 days, p=.000). Also, time to surgery decreased 29.4% in the multidisciplinary intervention group (6.23 vs. 4.4 days, p=.000). Patients assigned to the clinical pathway group showed higher medical complications rate (delirium, malnutrition, anaemia and electrolyte disorders), but a lower hospital mortality (5.10 vs. 2.87%, p>.005). The incidence of surgical wound infection (p=.031) and functional efficiency (p=.001) also improved in 2013. An increased number of patients started treatment for osteoporosis (14.80 vs. 76.09%, p=.001) after implementing the clinical pathway.

CONCLUSION

The implementation of a clinical pathway in the care process of elderly patients with hip fracture reduced length of stay and time to surgery, without a negative impact on associated clinical and functional outcomes.

Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults

OBJECTIVE

To evaluate the incidence, characteristics, and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture.

DESIGN

Retrospective cohort study using linked, population-based administrative data.

SETTING

Province of Ontario, Canada.

PARTICIPANTS

Older adults, aged 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003, and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (N=25,436).

MEASUREMENTS

We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression.

RESULTS

Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3-fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation.

CONCLUSION

The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed off-label in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.

Mortality and Revision Surgery Are Increased in Patients With Parkinson's Disease and Fractures of the Femoral Neck

BACKGROUND

Patients with Parkinson's disease are at increased risk for falls and associated hip fractures as a result of tremor, bradykinesia, rigidity, and postural instability. The available literature is limited and conflicting regarding the optimal surgical treatment and risk for postoperative complications and mortality in this unique patient population.

QUESTIONS/PURPOSES

We asked: (1) Is there a difference in mortality after surgical treatment of hip fractures in patients with Parkinson's disease compared with similar patients with hip fractures without Parkinson's disease? (2) Does Parkinson's disease lead to a higher rate of reoperation after operative treatment of femoral neck fractures? (3) Does Parkinson's disease lead to a higher rate of dislocation after hemiarthroplasty for displaced femoral neck fractures, and (4) does the operative approach affect dislocation rates?

METHODS

In this case-controlled study, we retrospectively reviewed 141 patients with a diagnosis of Parkinson's disease and a fracture of the femoral neck. Each patient with Parkinson's disease was matched with two control patients (n = 282) without Parkinson's disease stratified by age, sex, American Society of Anesthesiologists classification, and fracture type (nondisplaced/displaced). Clinical outcomes included mortality after surgical intervention, rate of reoperation, dislocation events after hemiarthroplasty, and the rate of failure after internal fixation for nondisplaced fractures.

RESULTS

The median survival time of the patients with Parkinson's disease after fracture was 31 months (95% CI, 25-37 months) compared with 45 months (95% CI, 39-50 months) in our control group (p = 0.007). The rate of reoperation for displaced and nondisplaced fractures was higher in the Parkinson's disease group compared with the control group (11% versus 4%; p = 0.005). Failure of fixation for patients treated with internal fixation of nondisplaced femoral neck fractures was significantly higher in the Parkinson's disease group compared with our control group (22% versus 5%; p = 0.01). Dislocation rates after hemiarthroplasty were significantly higher in the Parkinson's disease group compared with the control group (8% versus 1%; p = 0.003). Patients treated with a hemiarthroplasty through an anterolateral approach had a significantly lower dislocation rate compared with those treated with a posterior approach (2% versus 15%; p = 0.002).

CONCLUSIONS

Parkinson's disease is an independent predictor of mortality after femoral neck fracture and is associated with an increased rate of dislocation, revision surgery, and failure of internal fixation. Although patients with Parkinson's disease with a nondisplaced or valgus impacted femoral neck fracture may be treated with internal fixation, they are at significantly higher risk of failure of fixation compared with patients without Parkinson's disease. Use of a hemiarthroplasty through an anterolateral approach may reduce the likelihood of requiring a revision operation.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Intertrochanteric Femur Fracture Stability: A Surrogate for General Health in Elderly Patients?

Introduction:

Intertrochanteric (IT) femur fractures are common in elderly patients who are often in poor general health. Intertrochanteric fractures are classified as stable or unstable, taking into account fracture morphology and involvement of the posteromedial calcar. The purpose of this study is to determine whether IT fracture stability can be used as a marker for general health or as a predictor of postoperative medical complications in elderly patients.

Materials and Methods:

We reviewed the records of all patients treated for IT fractures at our institution over the past 7 years. We excluded patients who were younger than 60 years, polytraumatized, involved in high-energy mechanisms of injury, managed nonoperatively, with hardware from previous surgery, or missing preoperative radiographs. Ninety-three patients were included in the present series. Three orthopedic surgeons independently reviewed all preoperative radiographs and classified each fracture as either stable or unstable. Interrater reliability was .77 (substantial) and consensus designation was assigned by majority. We reviewed charts for age, gender, time to surgery, length of hospital stay, type of surgery, estimated blood loss, American Society of Anesthesiologists (ASA) classification, and postoperative medical complications. Univariate and multivariate statistical analyses were conducted to determine the relationship of fracture stability on ASA class and medical complications.

Results:

Intertrochanteric fracture stability had no detectable relationship with ASA class (P = .497). On univariate analysis, stability was not significantly related to medical complications (P = .421). Our multivariate analysis found that only ASA was related to medical complications (P = .004), and fracture stability was not related to complications (P = .538).

Conclusion:

Intertrochanteric fracture stability does not appear to be a marker for poor general health or to predict postoperative medical complications in elderly patients in this limited study. ASA class was predictive of medical complications. Interestingly, medical complications were 8% greater in patients with unstable fractures than in patients with stable fractures.

Osteoporotic Hip and Spine Fractures: A Current Review

Hip and spine fractures represent just a portion of the burden of osteoporosis; however, these fractures require treatment and often represent a major change in lifestyle for the patient and their family. The orthopedic surgeon plays a crucial role, not only in the treatment of these injuries but also providing guidance in prevention of future osteoporotic fractures. This review provides a brief epidemiology of the fractures, details the surgical techniques, and outlines the current treatment guidelines for orthopedic surgeons.

[Clinical pathway for hip fracture patients]

INTRODUCTION

Hip fracture in the elderly often occurs in patients with high co-morbidity. Effective management requires a comprehensive and multidisciplinary approach.

PURPOSE

To evaluate the effect of a quality improvement intervention in the detection and treatment of complications in elderly patients admitted for hip fracture.

MATERIAL AND METHODS

A comparative study was conducted between two groups of patients admitted for hip fracture prior to 2010, and after a quality improvement intervention in 2013. The intervention consisted of implementing improved multidisciplinary measures in accordance with recent scientific evidence. The degree of compliance of the implemented measures was quantified.

RESULTS

Patients admitted due to hip fracture in 2010 (216 patients) and 2013 (196 patients) were similar in age, sex, Barthel Index, and a reduced Charlson Index, although there were more comorbidities in 2013. After implementation of the protocols, the detection of delirium, malnutrition, anemia, and electrolyte disturbances increased. A larger number of patients in 2013 were precribed intravenous iron (24% more) and osteoporosis treatment (61.3% more). The average stay was reduced by 45.3% and surgical delay by 29.4%, achieving better functional efficiency.

CONCLUSION

The implementation of a clinical pathway in geriatric patients with hip fracture is useful to detect and treat complications at an early stage, and to reduce pre-operative and overall stay, all without a negative clinical or functional impact.

Male and female differences in musculoskeletal disease

Gender differences exist in the presentation of musculoskeletal disease, and recognition of the differences between men and women's burden of disease and response to treatment is key in optimizing care of orthopaedic patients. The role of structural anatomy differences, hormones, and genetics are factors to consider in the analysis of differential injury and arthritic patterns between genders.

Pre- and perioperative predictors of changes in mobility and living arrangements after hip fracture--a population-based study

PURPOSE OF THE RESEARCH

Examining pre- and perioperative predictors of changes in mobility and living arrangements after hip fracture.

MATERIALS AND METHODS

Population-based prospective data were collected on 1027 hip fracture patients aged ≥65. The outcomes were decreased vs. same or improved mobility level and need for more supported vs. same or less supported living arrangements 1 year after hip fracture. The independent variables were age, gender, body mass index, American Society of Anesthesiologists score, diagnosis of memory disorder, mobility level and living arrangements, fracture type, delay to surgery and urinary catheter removal during acute hospitalization.

THE PRINCIPAL RESULTS

Multivariate logistic regression analysis revealed the prefracture mobility level of walking outdoors (OR=0.47, 95% CI 0.30-0.75) or indoors (OR=0.25, 95% CI 0.09-0.72) assisted to be associated with a smaller decrease in mobility level. Non-independent mobility level (OR=2.74, 95% CI 1.70-4.41) was associated with the need of more supported living arrangements. Living in assisted living accommodations (OR=0.23, 95% CI 0.12-0.44) was associated with less need for more supported living arrangements. Removal of the urinary catheter showed a protective association on both decline in mobility level (OR=0.45; 95% CI 0.29-0.70) and moving to a more supported living arrangement(OR=0.49,95% CI 0.31-0.77.

MAJOR CONCLUSIONS

Worsening of mobility was significant for independent mobilizers. Prefracture impaired mobility was associated with the need of more supported living arrangements. Living in an assisted living accommodation protected against institutionalization. The findings emphasize the importance of a prompt removal of the urinary catheter after hip fracture.

An assessment of the inter-rater reliability of the ASA physical status score in the orthopaedic trauma population

OBJECTIVES

Although recent literature has demonstrated the utility of the ASA score in predicting postoperative length of stay, complication risk and potential utilization of other hospital resources, the ASA score has been inconsistently assigned by anaesthesia providers. This study tested the reliability of assignment of the ASA score classification by both attending anaesthesiologists and anaesthesia residents specifically among the orthopaedic trauma patient population.

METHODS

Nine case-based scenarios were created involving preoperative patients with isolated operative orthopaedic trauma injuries. The cases were created and assigned a reference score by both an attending anaesthesiologist and orthopaedic trauma surgeon. Attending and resident anaesthesiologists were asked to assign an ASA score for each case. Rater versus reference and inter-rater agreement amongst respondents was then analyzed utilizing Fleiss's Kappa and weighted and unweighted Cohen's Kappa.

RESULTS

Thirty three individuals provided ASA scores for each of the scenarios. The average rater versus reference reliability was substantial (Kw=0.78, SD=0.131, 95% CI=0.73-0.83). The average rater versus reference Kuw was also substantial (Kuw=0.64, SD=0.21, 95% CI=0.56-0.71). The inter-rater reliability as evaluated by Fleiss's Kappa was moderate (K=0.51, p<.001). An inter-rater comparison within the group of attendings (K=0.50, p<.001) and within the group of residents were both moderate (K=0.55, p<.001). There was a significant increase in the level of inter-rater reliability from the self-reported 'very uncomfortable' participants to the 'very comfortable' participants (uncomfortable K=0.43, comfortable K=0.59, p<.001).

CONCLUSIONS

This study shows substantial agreement strength for reliability of the ASA score among anaesthesiologists when evaluating orthopaedic trauma patients. The significant increase in inter-rater reliability based on anaesthesiologists' comfort with the ASA scoring method implies a need for further evaluation of ASA assessment training and routine use on the ground. These findings support the use of the ASA score as a statistically reliable tool in orthopaedic trauma.

ASA score as a predictor of 30-day perioperative readmission in patients with orthopaedic trauma injuries: an NSQIP analysis

OBJECTIVE

Our purpose was to identify the impact of the physical status of the American Society of Anesthesiologists (ASA) on the 30-day readmission of patients receiving operative management of orthopaedic fractures using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

We analyzed all patients with orthopaedic trauma injuries in the American College of Surgeons NSQIP database from 2005 to 2011. A total of 8761 patients representing 91 orthopaedic trauma procedures were identified and included in analysis after selection. Logistic regressions were conducted to identify the predictive ability of ASA on the likelihood of readmission for patients in each anatomic category (upper extremity, pelvis/acetabulum, lower extremity) and the combined study population.

RESULTS

The ASA physical status proved the strongest predictor of 30-day readmission for the selected orthopaedic trauma procedures. After controlling for age, gender, race, and medical comorbidities that were shown to be significant independent risk factors for readmission, ASA score continued to have a significant association on 30-day readmissions in the combined population (odds ratio = 1.45, 95% confidence interval = 1.13-1.88, P = 0.001). For the combined analysis, compared with patients with an ASA score of 1, patients with an ASA score of 2 were 1.04 times as likely to have a readmission (P = 0.001), patients with an ASA score of 3 were 3.77 times as likely to have a readmission (P = 0.001), and patients with an ASA score of 4 were 13.7 times as likely to have a readmission (P = 0.001).

CONCLUSIONS

ASA classification is an indicator for variance in readmission for patients receiving operative treatment of orthopaedic fractures. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. This model may be used to more accurately predict a patient's postoperative course and the expected risk for readmission, such that hospitals can target these "at-risk" individuals and reduce 30-day readmissions.

LEVEL OF EVIDENCE

Prognostic level II. See Instructions for authors for a complete description of levels of evidence.

Predicting mortality following hip fracture: an analysis of comorbidities and complications

BACKGROUND

Hip fracture is common in the geriatric population. These patients have multiple comorbidities that complicate treatment and recovery such that poor functional outcomes often result. Since functional outcomes are associated with comorbidities and complications it is important to define the contributing factors.

AIMS

To describe comorbidities common to geriatric hip fracture patients and determine predictability of complications and mortality based on comorbidities.

METHODS

Data in this study were sourced from information prospectively collected for evaluation of a new orthogeriatric service established at a University Teaching Hospital over the period of 1 year.

RESULTS

The median age was 82 years (range 54-100) and 73 % were female (N = 206). Common comorbidities included hypertension (51 %), dementia (28 %), osteoporosis (19 %), ischaemic heart disease (IHD) (15 %) and chronic obstructive pulmonary disease (15 %). In predicting 1-year mortality based on comorbidities, the final model included age, IHD, delay to surgery and explained 26 % of the variability in mortality. Predicting 1-year mortality based on complications, the final model included age and respiratory complications and explained 26 % of the variability in mortality. There was a significant association between having respiratory complications and chronic obstructive pulmonary disease (p < 0.001) with 63 % of those with respiratory complications having chronic obstructive pulmonary disease.

CONCLUSIONS

This study highlights specific patient comorbidities and medical complications that could be used to guide clinical assessment, management and targeted interventions that improve outcomes in this patient group.

The effect of osteoporotic treatment on the functional outcome, re-fracture rate, quality of life and mortality in patients with hip fractures: a prospective functional and clinical outcome study on 520 patients

Numerous high quality studies have shown the positive effects of various osteoporotic medical treatment regimens on bone mass and on the reduction of risk for new spinal, hip and non-spinal fractures in osteoporotic patients. However, the effect of osteoporotic treatment on the functional and clinical outcome of patients who have sustained hip fractures and been treated surgically has not yet been addressed. Five hundred and twenty patients out of 611 who were admitted (2009-2011), operated on due to a hip fracture and completed their follow-up evaluations were included in this study. Data related to functional outcome scores, re-fracture rate, quality of life and mortality rate were prospectively recorded, analysed and correlated to osteoporotic medical treatment. There were 151 (25%) men and 369 (71%) women with a mean age of 80.7 years (range, 60 to 90 years). At a mean follow-up of 27.5 months (range, 24 to 36 months) a mortality rate of 23.6% at 2 years was recorded. Mean values of functional and quality of life scores were found to have progressively improved within two years after surgery. Seventy-eight (15%) patients were taking osteoporotic treatment before their hip fracture and 89 (17.1%) started afterwards. Osteoporotic treatment proved to be an important predictor of functional recovery (all p values<0.05), re-fracture rate (p=0.028) and quality of life (EQ-5D, all dimensions, p values<0.05). Osteoporotic treatment did not affect post-fracture mortality rates. Osteoporotic treatment taken before or initiated after fracture is a strong predictor of functional and clinical outcome in patients with hip fractures treated surgically.

A new future for hip fracture care--orthogeriatrician lead in an 'Acute' Hip Unit

Although surgery is the definitive treatment for almost all hip fractures, there is evidence that outcomes such as morbidity and mortality are not determined by the type of surgery but by comorbidities and postoperative complications. A team approach, especially the involvement of an orthogeriatrician in managing medical issues, has been shown to improve surgical outcomes and should be encouraged in hospitals worldwide. An Acute Hip Unit is able to address the complex challenging needs of a frail older high-risk population soon after admission, therefore minimising delays. An orthogeriatrician-led unit can deal with the preoperative and complex postoperative medical, social, ethical, physical, and mental health issues that are associated with 'hip fracture syndrome', providing structured standardised evidence-based care by trained staff. This could be the model of care for the future.

Complications of hip fractures: A review

Nowadays, fracture surgery represents a big part of the orthopedic surgeon workload, and usually has associated major clinical and social cost implications. These fractures have several complications. Some of these are medical, and other related to the surgical treatment itself. Medical complications may affect around 20% of patients with hip fracture. Cognitive and neurological alterations, cardiopulmonary affections (alone or combined), venous thromboembolism, gastrointestinal tract bleeding, urinary tract complications, perioperative anemia, electrolytic and metabolic disorders, and pressure scars are the most important medical complications after hip surgery in terms of frequency, increase of length of stay and perioperative mortality. Complications arising from hip fracture surgery are fairly common, and vary depending on whether the fracture is intracapsular or extracapsular. The main problems in intracapsular fractures are biological: vascularization of the femoral head, and lack of periosteum -a major contributor to fracture healing- in the femoral neck. In extracapsular fractures, by contrast, the problem is mechanical, and relates to load-bearing. Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis, good pain control at the perioperative, detection and management of delirium, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and advancement of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients.

The effects of American Society of Anesthesiologists physical status on length of stay and inpatient cost in the surgical treatment of isolated orthopaedic fractures

OBJECTIVES

To identify the impact of the American Society of Anesthesiologists (ASA) physical status on postoperative length of stay (LOS) and to document the cost due to LOS after surgical management of the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic fractures.

DESIGN

Retrospective chart review.

SETTING

All patients who presented and underwent one of the 10 selected isolated orthopaedic surgical procedures at a large tertiary care center between January 1, 2000, and December 31, 2010.

PATIENTS/PARTICIPANTS

Charts for patients undergoing the 10 selected isolated orthopaedic surgical fracture procedures more than 10 years were reviewed. Thirteen thousand seven hundred seventy-six distinct operations were identified. One thousand three hundred ninety-eight distinct operations were included in analysis after selection.

INTERVENTION

This was an observational study. Patients who received operative management for isolated orthopaedic fractures were identified utilizing a CPT code search for analysis in a retrospective chart review.

MAIN OUTCOME MEASUREMENTS

LOS and cost secondary to LOS.

RESULTS

ASA physical status proved the strongest predictor of postoperative LOS for the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic procedures. ASA was also a significant predictor of inpatient cost for all isolated orthopaedic procedures included in the study with the exception of CPT code 27536.

CONCLUSIONS

ASA classification is an indicator for variance in LOS and total inpatient cost for hospitalized patients. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. In addition, this study provides a foundation for many other studies to be conducted which will include multiple institutions and fracture types, such that ASA can be used as a more generalizable predictor of LOS and inpatient cost in orthopaedic trauma patients. This model may be used to accurately predict a patient's postoperative course and the expected cost to the health care system of a given procedure.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Proximal femoral nail antirotation in treatment of fractures of proximal femur

Introduction:

Fractures of the proximal femur and hip are relatively common injuries in adults and common source of morbidity and mortality among the elderly. Many methods have been recommended for the treatment of intertrochanteric fractures.

Material and methods:

We retrospective analyzed all the patients with fractures of the hip treated with proximal femoral nail antirotation (PFNA) at the Clinic of Orthopedic and Traumatology, University Clinical Centre Tuzla from the first of January 2012 to 31 December 2012 years. The study included 63 patients averaged 73.6±11.9 years (range, 29 to 88 years). Fracture type was classified as intertrochanteric (Arbeitsgemeinschaft für Osteosynthesefragen classification 31.A.1, A.2 and A.3) and subtrochanteric fractures (Seinsheimer classification).

Results and discussion:

The ratio between the genders female-male was 1.6:1. There was statistically significant difference prevalence of female compared to male patients (p=0.012). There were 31 left and 32 right hip fractured. Low energy trauma was the cause of fractures in 57(90.5%) patients. Averaged waiting time for hospitalization was 3.2±7.5 days (range, 0 to 32 days). 44 patients were admitted the same day upon injuring. The average waiting time for the treatment was 3.6±5.7 days. The ratio between with or without co-existent disease was 4.7:1. During the three months postoperatively with ASA score 3 and 4 six patients died. There were no significant differences in deaths from ASA score 1 and 2 (p=0.52). Reoperation for the treatment of implant or fracture-related complications was required in three (4.7%) patients (infection, reimplantation and extraction). Three patient developed deep vein thrombosis. Statistically significant difference was found in the deaths in the first three months compared to the next three months (p=0.02). We found statistically significant difference between pre-injury and postoperative mobility score (p=0.0001).

Conclusion:

PFNA is an excellent device for osteosynthesis as it can be easily inserted. Moreover, it provides stable fixation, which allows early full weightbearing mobilization of the patient.

Geriatric Hip Fractures and Inpatient Services: Predicting Hospital Charges Using the ASA Score

Purpose. To determine if the American Society of Anesthesiologist (ASA) score can be used to predict hospital charges for inpatient services. Materials and Methods. A retrospective chart review was conducted at a level I trauma center on 547 patients over the age of 60 who presented with a hip fracture and required operative fixation. Hospital charges associated with inpatient and postoperative services were organized within six categories of care. Analysis of variance and a linear regression model were performed to compare preoperative ASA scores with charges and inpatient services. Results. Inpatient and postoperative charges and services were significantly associated with patients' ASA scores. Patients with an ASA score of 4 had the highest average inpatient charges of services of $15,555, compared to $10,923 for patients with an ASA score of 2. Patients with an ASA score of 4 had an average of 45.3 hospital services compared to 24.1 for patients with a score of 2. Conclusions. A patient's ASA score is associated with total and specific hospital charges related to inpatient services. The findings of this study will allow payers to identify the major cost drivers for inpatient services based on a hip fracture patient's preoperative physical status.

Mortality after proximal femur fracture with a delay of surgery of more than 48 h

PURPOSE

For hip fractures, guidelines require surgery as soon as possible, but not later than 48 h. Some authors observed a positive and some a negative effect of early operation on mortality rate. The aim was to evaluate the mortality rate of patients with a delay of surgery >48 h after admission, as well as influencing factors and reasons for delay.

METHODS

One hundred and thirty-six patients with hip fractures (>65a) from 2007 to 2011 were included. Comorbidities, the American Society of Anaesthesiologists (ASA) classification, time of admission and surgery, and mortality were recorded up to 12 months. Reasons for delay were divided into administrative-related or patient-related. The following time intervals were observed: 48.01-72 h (2-3 days), 72.01-120 h (3-5 days), 120.01-168 h (5-7 days), 168 h (>7 days).

RESULTS

94.9 % of the reasons for delay were patient-related. The mean survival times of the first three intervals were almost the same (9.5-9.9 months) (p = 0.75). The last group had a significantly shorter survival time (7.8 months). Summarizing the first three groups, a significant shorter (p = 0.03) survival time and significantly higher (p = 0.04) 12-month mortality rate in patients with a delay >7 days was observed. The probability of death was primarily dependent on the ASA classification (p < 0.0001) and secondarily on the patient's age at the time of injury (p = 0.005).

CONCLUSIONS

In hip fractures, reasons for a delay >48 h are mainly patient-related. A delay up to 7 days did not influence survival time and mortality negatively. The higher the value of the ASA classification and the older the patient was at the time of injury, the higher the mortality rate and the shorter the survival time.

Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

BACKGROUND AND PURPOSE

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

METHODS

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

RESULTS

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients' satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

CONCLUSION

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Multiple testing in orthopedic literature: a common problem?

Background

Performing multiple tests in primary research is a frequent subject of discussion. This discussion originates from the fact that when multiple tests are performed, it becomes more likely to reject one of the null hypotheses, conditional on that these hypotheses are true and thus commit a type one error. Several correction methods for multiple testing are available. The primary aim of this study was to assess the quantity of articles published in two highly esteemed orthopedic journals in which multiple testing was performed. The secondary aims were to determine in which percentage of these studies a correction was performed and to assess the risk of committing a type one error if no correction was applied.

Methods

The 2010 annals of two orthopedic journals (A and B) were systematically hand searched by two independent investigators. All articles on original research in which statistics were applied were considered. Eligible publications were reviewed for the use of multiple testing with respect to predetermined criteria.

Results

A total of 763 titles were screened and 127 articles were identified and included in the analysis. A median of 15 statistical inference results were reported per publication in both journal A and B. Correction for multiple testing was performed in 15% of the articles published in journal A and in 6% from journal B. The estimated median risk of obtaining at least one significant result for uncorrected studies was calculated to be 54% for both journals.

Conclusion

This study shows that the risk of false significant findings is considerable and that correcting for multiple testing is only performed in a small percentage of all articles published in the orthopedic literature reviewed.

Changes in hip fracture incidence, mortality and length of stay over the last decade in an Australian major trauma centre

PURPOSE

The aim of this study was to describe the population-based longitudinal trends in incidence, 30-day mortality and length of stay of hip fracture patients in a tertiary referral trauma centre in Newcastle, New South Wales, Australia, and identify the factors associated with increased 30-day mortality.

METHODS

A retrospective database and chart review was conducted to patients aged ≥65 years with a diagnosis of femoral neck or pertrochanteric fracture admitted to the John Hunter Hospital between 01 January 2002 and 30 December 2011. The main outcome measure was 30-day mortality; secondary outcome was acute length of stay.

RESULTS

There were 4,269 eligible patients (427±20 per year) with hip fractures over the 10-year study period. The absolute incidence increased slightly (p=0.1) but the age-adjusted rate decreased (p≤0.0001). The average age (83.5±7.1 years) and percentage of females (73.7%) did not change. Length of stay increased by a factor of 2.5% per year (p<0.0001). Thirty-day mortality decreased from 12.3% in 2002 to 8.20% in 2011 (p=0.0008). Independent risk factors associated with increased 30-day mortality were longer admissions (p<0.0001), increased age (p=0.005), dementia (p=0.01), male gender (p<0.0001), higher American Society of Anaesthesiologists score (p<0.0001), and longer time to operating theatre (p=0.002).

CONCLUSIONS

Despite the relative ageing of our population, a decrease in the age-standardised rate of fractured hip in elderly patients has seen the number of admissions remain unchanged in our institution from 2002 to 2011. There was a decrease in 30-day mortality, while length of stay increased.

Systemic inflammatory responses and lung injury following hip fracture surgery increases susceptibility to infection in aged rats

Pulmonary infections frequently occur following hip fracture surgery in aged patients. However, the underlying reasons are not fully understood. The present study investigates the systemic inflammatory response and pulmonary conditions following hip fracture surgery as a means of identifying risk factors for lung infections using an aged rodent model. Aged, male Sprague-Dawley rats (8 animals per group) underwent a sham procedure or hip fracture plus femoral intramedullary pinning. Animals were sacrificed 1, 3, and 7 days after the injury. Markers of systemic inflammation and pulmonary injury were analyzed. Both sham-operated and injured/surgical group animals underwent intratracheal inoculation with Pseudomonas aeruginosa 1, 3, and 7 days after surgery. P. aeruginosa counts in blood and bronchoalveolar lavage (BAL) fluid and survival rates were recorded. Serum TNF-α, IL-6, IL-1β, and IL-10 levels and markers of pulmonary injury were significantly increased at 1 and 3 days following hip fracture and surgery. Animals challenged with P. aeruginosa at 1 and 3 days after injury had a significantly decreased survival rate and more P. aeruginosa recovered from blood and BAL fluid. This study shows that hip fracture and surgery in aged rats induced a systemic inflammatory response and lung injury associated with increased susceptibility to infection during the acute phase after injury and surgery.

Reoperation rate after internal fixation of intertrochanteric femur fractures with the percutaneous compression plate: what are the risk factors?

OBJECTIVE

The aim was this study was to analyze the risk factors for reoperation after internal fixation of intertrochanteric fractures of the femur using the percutaneous compression plate (PCCP).

DESIGN

This was a retrospective cohort study.

SETTING

The study was conducted at the University Hospital.

PATIENTS AND METHODS

Patients with intertrochanteric femur fractures who underwent internal fixation with a PCCP were included in this study. We investigated potential risk factors such as age, gender, body mass index, comorbidities of the patients (American Society of Anesthetist classification), type of fracture (AO/OTA classification), experience of the surgeons (in terms of the number of surgical procedures with the PCCP device), tip-apex distance (TAD), and operation time. The procedures were performed by 10 surgeons. Logistic regression was used to assess potential predictors for the need of reoperation.

RESULTS

Of the 96 patients with 96 intertrochanteric fractures, 8 underwent reoperation due to local complications (8.3%). The most frequent complication was complete or imminent cutting out of the upper cervical screw (N = 5; 5.2%). Five of the 8 risk factors that were associated with reoperation in the initial univariable analyses with a P value of <0.20 were retained in a multivariable logistic regression model, including, age, body mass index, TAD, experience of the surgeons, and operation time. Of these, only the factor TAD proved to be a significant predictor for reoperation (P = 0.027, odds ratio = 1.089, 95% confidence interval 1.01-1.175).

CONCLUSIONS

Our data show that the surgeon-related risk factors (number of operations, operation time, TAD) seem to be more relevant for the reoperation rate after internal fixation with the PCCP device when compared with the patient-related risk factors. This finding indicates a substantial learning curve for this technically demanding procedure.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of preoperative skin traction for hip fractures: a single-institution prospective randomized controlled trial of skin traction versus no traction

BACKGROUND

Preoperative traction for hip fractures is of no benefit in semi-urgent surgery. However, its efficacy has not been assessed in cases in which emergency surgery was not possible. We evaluated the efficacy of preoperative skin traction for hip fractures in a level II trauma center in Japan where many patients undergo delayed surgery.

METHODS

We undertook a randomized controlled trial. Eighty-one patients were randomized to be treated with skin traction (41 patients), or bed rest (40 patients). Preoperative pain was assessed by use of a visual analogue scale and the number of analgesics required. Fracture reduction was measured on the basis of leg-length and neck-shaft angle discrepancies on the radiograph on admission, a day before surgery, and after surgery.

RESULTS

The mean time from admission to surgery was 7.5 days. Pain decreased markedly on the day after admission in both the traction and no-traction groups. No significant difference was found during the preoperative waiting period between the groups in either pain score or number of analgesics taken. No significant difference was found in radiographic data either before or after surgery, and satisfactory reduction was achieved after surgery irrespective of the use of skin traction.

CONCLUSIONS

In our single-institution prospective randomized controlled trial, preoperative skin traction for patients with hip fracture had no effect on pain relief before surgery or reduction of fracture displacement during surgery, irrespective of preoperative waiting time.

Patient variables which may predict length of stay and hospital costs in elderly patients with hip fracture

OBJECTIVES

To investigate what factors contribute to increased length of stay (LOS) and increased costs in treatment of elderly patients with hip fractures.

DESIGN

Retrospective chart review.

SETTING

All patients who presented to a large tertiary care center between January 2000 and December 31, 2009.

PARTICIPANTS

Charts for all patients older than 60 years who presented with isolated low-energy hip fractures were reviewed. Of the 719 patients identified, 660 were included.

INTERVENTION

Patients who underwent operative fixation or hemiarthroplasty secondary to hip fracture were identified using a search of Current Procedural Terminology (CPT) codes search.

MAIN OUTCOME MEASUREMENTS

Gender, height, weight, body mass index, length of procedure, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were gathered and compared with LOS and direct daily inpatient hospital cost.

RESULTS

No correlation existed between body mass index or specific comorbidities and LOS, but ASA classification was a predictor. For each ASA increase of 1, average LOS increased 2.053 days (P < 0.001). Given total daily cost to the hospital for these patients was $4530, each increase in ASA classification translated to an increase of $9300.

CONCLUSIONS

ASA classification proved useful in estimating LOS and cost for patients undergoing operative fixation of hip fractures. Because ASA classification and cost are universally collected, this method can be employed in almost any hospital. This highlights a role for ASA classification in preoperative estimation of the elderly patient's cost and a potential advantage for incorporating patient factors in the development of tiered reimbursement models.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Safety and efficacy of intravenous acetaminophen in the elderly after major orthopedic surgery: subset data analysis from 3, randomized, placebo-controlled trials

As the number of patients aged 65 years and older increases, joint replacement has become a frequent procedure after progressive osteoarthritis or fractures. Although hip and knee arthroplasty has become a relatively commonplace procedure in this age-group, the advanced age in patients undergoing these procedures often is associated with comorbidities and potential complications that can present challenges and limit analgesic choices. This subset analysis is designed to determine the efficacy and safety of intravenous (IV) acetaminophen in the elderly subpopulation from 3 placebo-controlled studies conducted to document the safety and efficacy of IV acetaminophen. A total of 231 patients were enrolled in the 3 trials, and of these, a total of 107 patients (46%) were aged 65 years or older. Across the studies, safety and efficacy were well documented in the elderly subpopulation and were comparable with the subpopulation younger than 65 years. A review of the literature similarly demonstrates the efficacy and safety of IV acetaminophen used for postoperative analgesia after joint replacement.

EVALUATION OF THE MORTALITY RATE ONE YEAR AFTER HIP FRACTURE AND FACTORS RELATING TO DIMINISHED SURVIVAL AMONG ELDERLY PEOPLE

OBJECTIVE

To evaluate the mortality rate after one year and correlated preoperative factors, among patients with hip fractures.

METHODS

We prospectively studied 202 out of a total of 376 patients with a diagnosis of hip fracture who were admitted to the Hospital Cristo Redentor, between October 2007 and March 2009. The database with the epidemiological analysis was set up during their hospitalization, and follow-up data were obtained preferentially by phone.

RESULTS

The overall mortality rate after one year of follow-up was 28.7% or 58 deaths, among which 11 (5.45%) occurred during hospitalization. Fractures were more prevalent among women (71.3%) and rare among blacks (5%). Among the comorbidities, dementia and depression showed a statistically significant reduction in survival (p = 0.018 and 0.007, respectively).

CONCLUSION

The mortality rate after one year of follow-up was 28.7%. Dementia and depression increased this rate.

Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial

Pertrochanteric fractures are a rising major health-care problem in the elderly and their operative stabilisation techniques are still under discussion. Furthermore, complications like cut-out are reported to be high and implant failure often is associated with poor bone quality. The PFNA(®) with perforated blade offers a possibility for standardised cement augmentation using a polymethylmethacrylate (PMMA) cement which is injected through the perforated blade to enlarge the load-bearing surface and to diminish the stresses on the trabecular bone. The current prospective multicentre study was undertaken to evaluate the technical performance and the early clinical results of this new device. In nine European clinics, 59 patients (45 female, mean age 84.5 years) suffering from an osteoporotic pertrochanteric fracture (Arbeitsgemeinschaft für Osteosynthesefragen, AO-31) were treated with the augmented PFNA(®). Primary objectives were assessment of operative and postoperative complications, whereas activities of daily living, pain, mobility and radiologic parameters, such as cement distribution around the blade and the cortical thickness index, were secondary objectives. The mean follow-up time was 4 months where we observed callus healing in all cases. The surgical complication rate was 3.4% with no complication related to the cement augmentation. More than one-half of the patients reached their prefracture mobility level within the study period. A mean volume of 4.2ml of cement was injected. We did not find any cut-out, cut through, unexpected blade migration, implant loosening or implant breakage within the study period. Our findings lead us to conclude that the standardised cement augmentation using the perforated blade for pertrochanteric fracture fixation enhances the implant anchorage within the head-neck fragment and leads to good functional results.

Perioperative implications of surgery in elderly patients with hip fractures: an evidence-based review

Hip fracture is a major cause of morbidity, mortality and loss of independence for the elderly. Surgical fixation of the fractured hip remains the standard of care to allow for early mobilisation and a return to independence. Operative management in this population carries its own set of problems. The altered physiological state of the older person, often coupled with significant comorbidity, can present challenges for the anaesthetist, the surgeon and the rest of the perioperative team. This article provides an evidence-based review of the important perioperative factors associated with hip fractures in the older person and their management.

Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach

INTRODUCTION

Surgical site infections (SSIs) are the most common nosocomial infections after surgery.However, clinical guidance on how to handle any suspicious clusters of SSI in orthopaedic surgery is missing. We report on problem analysis and solution finding following the observation of an increased rate of SSI in trauma implant surgery.

SETTING

Trauma unit of a university hospital.

METHODS

Over a 2-year observation period, all patients (n = 370) following surgical stabilisation of proximal femur fractures in a trauma unit of a university hospital were consecutively followed using a standardised case report form. First, a retrospective cohort of 217 patients was collected for whom an increased SSI rate was detected. Based on risk analysis, new standard perioperative procedures were developed and implemented. The impact was evaluated in a prospective cohort of 153 comparable patients. Uni- and multivariable analysis of factors associated with the risk for SSI was undertaken.

RESULTS

The intervention bundle resulted in a significant reduction of an initially increased SSI incidence of 6.9 (down) to 2.0% (p = 0.029). Multivariable analysis revealed four risk factors significantly associated with a higher risk of SSI caused by different bacteria: duration of surgery (p = 0.002), hemiarthroplasty(p = 0.002), haematoma (p = 0.004) and the presence of two operating room staff members (p < 0.001 and 0.035).

CONCLUSIONS

A standardised prospective SSI protocol and detection system offering the simultaneous use of data should guarantee every institution immediate alarm registration to avoid comparable problem situations. Detailed interdisciplinary analysis followed by the implementation of coherent interventions, based on a best-evidence structured bundle approach, may adequately resolve similar critical incidence episodes.