Daytime versus after-hours surgery outcomes in hip fracture patients: a systematic review and meta-analysis

Proximal Femur Fractures: Evaluating the Necessity of On-Call Surgery

Background: The decision of the Joint Federal Committee on the treatment of hip fractures stipulates that proximal femur fractures must be treated within the first 24 h. This leads to organizational and personnel difficulties in day-to-day care. Therefore, we investigated the question at what times of day we operate to maintain this timeline and whether there is a difference in the outcome for the patients according to treatment hours. Methods: Data from the DGU's "AltersTraumaRegister" from 2016 to 2020 were analyzed. For the analysis, the patients were divided into seven cohorts depending on the time of surgery. Pre-operative, operative, and follow-up data were analyzed. Results: A total of 29,470 patients were included in our study. The results showed that 74% of patients were treated within 24 h. 72% of patients operated on between 0-7 h had pertrochanteric fractures, while 56% of all arthroplasties were performed during normal working hours. In supra-regional trauma centers, significantly fewer operations were performed during normal working hours, while significantly more surgeries were carried out in the late evening and at night (p < 0.001). There were no significant differences in mortality and morbidity between the individual groups. Conclusions: Although we manage to treat most patients within 24 h, only 46% of patients are operated on within normal working hours. In terms of the outcome parameters, this does not appear to be a disadvantage for the patients. Nevertheless, night work and fatigue affect concentration and post-operative results in many areas, as we know. Consequently, patient care during normal working hours within 24 h creates the best possible initial situation for the patient, as significantly more personnel resources are available during normal working hours. The aim should be to create the logistical and personnel requirements for this.

Time to surgery after proximal femur fracture in geriatric patients depends on hospital size and provided level of care: analysis of the Registry for Geriatric Trauma (ATR-DGU)

PURPOSE

Proximal femur fractures predominantly affect older patients and can mark a drastic turning point in their lives. To avoid complications and reduce mortality, expert associations recommend surgical treatment within 24-48 h after admission. Due to the high incidence, treatment is provided at a wide range of hospitals with different size and level of care, which may affect time to surgery.

METHODS

Data from 19,712 patients included from 2016 to 2019 in the Registry for Geriatric Trauma (ATR-DGU) were analyzed in terms of time to surgery, in-house mortality, mobilization on the first postoperative day, ambulation status on the 7th day after surgery, and initiation of osteoporosis therapy. Participating hospitals were grouped according to their classification as level I, II or III trauma centers. Also presence of additional injuries, intake and type of anticoagulants were considered. Linear and logistic regression analysis was performed to evaluate the influence of hospitals level of care on each item.

RESULTS

28.6% of patients were treated in level I, 37.7% in level II, and 33.7% in level III trauma centers. There was no significant difference in age, sex and ASA-score. Mean time to surgery was 19.2 h (IQR 9.0-29.8) in level I trauma centers and 16.8 h (IQR 6.5-24) in level II/III trauma centers (p < 0.001). Surgery in the first 24 h after admission was provided for 64.7% of level I and 75.0% of level II/III patients (p < 0.001). Treatment in hospitals with higher level of care and subsequent increased time to surgery showed no significant influence on in-house mortality (OR 0.90, 95%-CI 0.78-1.04), but negative effects on walking ability 7 days after surgery could be observed (OR 1.28, 95%-CI 1.18-1.38).

CONCLUSION

In hospitals of larger size and higher level of care the time to surgery for patients with a proximal femur fracture was significantly higher than in smaller hospitals. No negative effects regarding in-house mortality, but for ambulation status during in-hospital stay could be observed. As the number of these patients will constantly increase, specific treatment capacities should be established regardless of the hospitals size.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Impact of sleep deficiency on surgical performance: a prospective assessment

STUDY OBJECTIVES

Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear.

METHODS

Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call.

RESULTS

Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time.

CONCLUSIONS

Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency.

CITATION

Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Comparison of daytime and after-hours surgical treatment of femoral neck fractures

Background

The timing of surgery for femoral neck fractures in young adults remains controversial. Nonetheless, the debate continues about whether orthopedic trauma cases should be operated daytime or after hours.

Aim

This study compared the clinical and radiological outcomes of surgery on femoral neck fractures during daytime versus after-hours.

Patients and Methods

A total of 124 patients aged 18-60 years who were operated for femoral neck fractures between 2015 and 2020 were included in the study. The patients were separated into two groups. Seventy-two patients operated between 08:00 and 17:00 hours were defined as the daytime group and 52 patients operated between 17:01 and 07:59 hours were defined as the after-hours group. Demographic data, reduction quality, duration of operation, intraoperative estimated blood loss (EBL), postoperative complications, revision rates, and postoperative Harris hip score results of the two groups were recorded for analysis.

Results

There was no significant difference between the groups in terms of age, gender, body mass index, smoking, fracture type and follow-up time, reduction quality, postoperative complication rates, revision rates, and Harris hip score results. Waiting times until surgery, operation duration, and intraoperative EBL amounts were, in the daytime group, significantly higher than in the after-hours group.

Conclusion

In this study comparing femoral neck fractures operated on daytime and after-hours in adults, the waiting time until surgery was found to be higher in the daytime group. Operation duration and EBL were higher in the after-hours group.

Postoperative subtype P as a risk factor for excessive postoperative sliding of cephalomedullary nail in femoral trochanteric fractures in old patients: A case series of 263 patients using computed tomography analysis

INTRODUCTION

Although excellent results of cephalomedullary nailing for femoral trochanteric fractures have been reported, excessive sliding has recently been noted as a cause of lag screw cut-out. Excessive sliding is reported as sliding of ≥8mm, which occurs in approximately 40%of cases. This study aimed to evaluate the risk factors for excessive sliding.

PATIENTS AND METHODS

Overall, 551 patients who underwent cephalomedullary nail surgery between 2016 and 2021 were recruited. Patients aged ≥65 years who underwent preoperative computed tomography (CT), experienced low-energy trauma, and received follow-up for >4 months were included. Cases were retrospectively reviewed for their postoperative sliding distance and the percentage of excessive sliding (>8 mm). 3D-CT classification, reduction pattern (subtypes A, N, and P) in the lateral view, medullary mismatch, and implant type (short/long Gamma3 nail and INTERTAN) were investigated fortheirimpact on sliding distance andtheincidence of excessive sliding. Complication rates (lag screw cut-out and non-union) were also assessed.

RESULTS

Overall, 263 patients (mean age, 84.0±7.4; 186 women) were recruited. The median (range) sliding distance was 3.5 (0-20) mm, and 42 cases (16.0%) had excessive sliding. Sliding distance was significantly smaller in the 2-fragment group than in the 3-fragment group (GP+GA and GP+L) (p=0.02); however, there were no significant differences between the 2-fragment and other fracture-type groups, including the 3-fragment group (GP, GA, GP ± GA, GP ± L), 4-fragmentgroup(GP/L, GP ± L/GA, GP±GA/L), and 5-fragmentgroup. There was no significant difference in sliding distance according to postoperative reduction type between the groups (p=0.83) and no correlation between medullary mismatch and sliding distance. The amount of sliding and rate of excessive sliding were significantly lower in the INTERTAN group than in the Gamma3 nail groups (p<0.01). Logistic regression analysis with excessive sliding as the variable revealed reduction type P as the only risk factor (p=0.024, odds ratio 2.99). There were three lag screw cut-out (1.1%) cases and one non-union (0.4%) case.

CONCLUSIONS

Postoperative subtype P is a risk factor for excessive sliding; there was significantly less sliding in the INTERTAN nail group. It is necessary to avoid reduction to subtype P to prevent postoperative excessive sliding.

LEVEL OF EVIDENCE

IV.

The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study

Purpose

The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day.

Methods

All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00–17:00) and out-of-hours surgery (17:00–08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality.

Results

Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00–1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01–1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04–1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01–1.15), p = 0.022] compared to on-hour surgery.

Conclusion

Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

Dedicated hip fracture services: A systematic review

BACKGROUND

Hip fractures (HFs) are common and pose a significant burden to both the individual and the community. Prompt operative management and aggressive rehabilitation have been shown to improve outcomes. However, there is often a delay in treatment due to lack of theatre availability and appropriate perioperative multi-disciplinary care. This study reviews the literature and reports on outcomes of HFs treated in dedicated units with allocated theatre time and pre-determined multi-disciplinary perioperative pathways. It also provides comparison against outcomes data from HF registries, both domestically and internationally.

METHODS

An electronic literature search was performed to identify original, English language studies reporting on patient outcomes from dedicated HF units (HFUs). Studies were graded using the Journal of Bone and Joint Surgery criteria. Data were extracted from the text, table and figures of the selected studies.

RESULTS

Five appropriate studies, with a total cohort of 6633 patients (4032 of whom were treated in a dedicated HFU), were identified. Patients treated in these units sustained a lower mortality rate (Risk Ratio  = 0.62, p = 0.01).

CONCLUSIONS

This review demonstrates that centres with dedicated HFUs result in improved 30-day mortality. Further research may demonstrate more sustained improvements in outcomes. The implementation of dedicated HFUs within health systems should be considered.

Hip fracture surgery performed out-of-hours-A systematic review and meta-analysis

INTRODUCTION

. Early hip fracture surgery (<48 hours) has shown to improve mortality for geriatric patients and is recommended in national hip fracture guidelines. However, this may be at the expense of surgery being performed out-of-hours where concerns about mortality risk exist. A systematic review and meta-analysis were performed to determine the mortality risk for hip fracture surgery performed in-hours (IH) compared to out-of-hours (OH), and on weekdays (WD) compared to weekends (WE).

MATERIALS AND METHODS

. A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from the dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.

RESULTS

. A total of 13 studies with 177,090 patients were included for analysis. Overall, there was no statistically significant difference for 30-day or inpatient mortality in IH vs OH groups (RR 0.93, p=0.46 and RR 1.16, p=0.63) and for WD vs WE groups (RR 0.98, p=0.73 and RR 0.76, p=0.67). There was no difference in length of stay between groups (p>0.05). The number of patients with American Society of Anaesthesiology (ASA) physical status classification ≥3 and male gender between the groups were similar (p>0.05).

CONCLUSION

. Performing hip fracture surgery OH or on the WE does not appear to increase the risk of 30-day or inpatient mortality or post-operative complications. Consideration should be given to performing hip fracture surgery out-of-hours to meet national guidelines (<48 hours).