[Osteosynthetic treatment of proximal femoral fractures: the timing of treatment is delayed in cases of pre-existing anticoagulation : Results of the data of external inpatient quality assurance from North Rhine-Westphalia with 24,786 cases within the framework of using secondary data]

Proximal Femur Fractures - How Decisive are Reduction and the Chosen Implant?

Proximal femoral fractures are frequent and complex injuries requiring prompt and targeted care. Numerous treatment strategies have been described, some of which have been assessed and clinically implemented clinically. The aim of surgical is always the restoration of a pain-free and stable extremity. Mostly elderly patients are affected and treatment is associated with high postoperative complications and mortality rates. With increasing numbers of patients, the topic is of great medical and economic relevance. In this work, the choice of implants for the osteosynthesis of proximal femoral fractures - as depending on the fracture type - will be examined, as based on a review of current literature. Standard care includes cannulated screws, sliding hips screws and cephalomedullary nails. In addition, the influence of implant positioning, fracture reduction and additional measures such as cement augmentation are evaluated and discussed. Careful fracture reduction and the quality of implant positioning are paramount in order to avoid complications.

[Long-term anticoagulation treatment in proximal femoral fractures as obstacle to surgery in the 24h time window? : Results of an analysis of Quality Assurance data on 32,252 treatment courses with osteosynthesis]

BACKGROUND

Both in Germany and internationally there is a vehement controversy about the appropriate time for care of proximal femoral fractures in older patients. The effort to achieve high quality and uniform standards of care culminated in the German healthcare system in the strict requirement of delay-free surgery within 24 h. Until now, in view of their high vulnerability patients who were severely injured were too often operated on late with the reference to a general medical condition that could be improved preoperatively. In particular, the fear of complications due to a pre-existing long-term anticoagulation treatment was repeatedly emphasized.

OBJECTIVE

The present study is dedicated to the question of whether a delay in surgery of anticoagulated patients with proximal femoral fractures already during the inpatient course has a detrimental effect on the complication statistics and the mortality of the patients. The extent to which external quality assurance data are suitable for rebutting any objections to an operation as soon as possible are examined.

MATERIAL AND METHODS

The study is based on treatment data from the external inpatient quality assurance procedure of the federal state of North Rhine-Westphalia from the years 2018-2020. Patients with a proximal femoral fracture were considered. This includes femoral neck fractures and fractures in the area of the pertrochanteric to subtrochanteric region. Only cases with joint-preserving fracture care were selected. The data sets were analyzed using suitable statistical software.

RESULTS

More general complications and deaths have been observed in anticoagulated patients. The trend of delayed fracture treatment under anticoagulant medication continues to be clearly visible. A positive association between longer preoperative waiting time and undesirable courses can be confirmed.

CONCLUSION

With respect to fracture care when taking anticoagulants, it must be critically examined to what extent a rapid normalization of the coagulation situation is necessary and this actually improves the chances of low complication courses. Should the elimination of the anticoagulant effect by substitution or antidote appear necessary, this should not prevent early care.

[Development of the inpatient quality of care of surgically treated patients with a proximal femoral fracture in North Rhine-Westphalia : Analysis of 61,249 treatment courses based on data from external inpatient quality assurance]

BACKGROUND AND OBJECTIVE

Every year in Germany over 100,000 people, mostly of older age, suffer a proximal femoral fracture. Increasing case numbers in connection with an aging population and a relatively large number of concomitant diseases requiring treatment make everyday care more difficult. It is therefore of great importance to observe the quality of care for these patients using relevant quality parameters in order to be able to derive implications for everyday treatment practice.

MATERIAL AND METHODS

The data of the external inpatient quality assurance from North Rhine-Westphalia for the years 2007-2008 and 2017-2018 were analyzed and the time periods compared. In addition, based on the documented secondary diagnosis and other influencing parameters, a risk adjustment was carried out with the aid of a logistic regression model with respect to the outcomes of general and surgical complications and mortality. Both osteosynthetically and endoprosthetically treated patients were taken into account. A total of 61,249 cases were included in the study.

RESULTS

Positive developments could be observed in the area of surgical complications and wound infections with decreases of 1.2% and 0.8%, respectively. Patients with cardiovascular diseases had a particularly poor outcome. Here, improvements in the subcategory of cardiovascular events were found for general complications. The mortality remained unchanged at 6%. Operative activity on the weekends increased significantly. Patients whose hospital admission was related to the weekend did not show an increased risk of complications or mortality. Although the proportion of patients who were operated on after more than 48 h was reduced from 11.4% to 8.2%, the operation (> 24 h) was still delayed in 26.8% of cases.

CONCLUSION

Against the background of increasing performance demands on the healthcare system, the results document improvements in some central areas of inpatient treatment. Nevertheless, the development of strategies for the further reduction of the preoperative waiting times in a medically justifiable manner is required. Internal concomitant diseases have a decisive influence on patient outcome. Thus, an adequate treatment of the multimorbid patient collective is to be established in everyday practice on the basis of close cooperation between geriatric traumatology and geriatric internal medicine departments.