The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced subcapital hip fractures in two trauma centres

Contextual Determinants of Time to Surgery for Patients With Hip Fracture

Importance

Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.

Objective

To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.

Design, Setting, and Participants

This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.

Main Outcomes and Measures

Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).

Results

A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.

Conclusions and Relevance

In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

Predictive analysis of lower limb fractures in the orthopedic complex operative unit using artificial intelligence: the case study of AOU Ruggi

The length of stay (LOS) in hospital is one of the main parameters for evaluating the management of a health facility, of its departments in relation to the different specializations. Healthcare costs are in fact closely linked to this parameter as well as the profit margin. In the orthopedic field, the provision of this parameter is increasingly complex and of fundamental importance in order to be able to evaluate the planning of resources, the waiting times for any scheduled interventions and the management of the department and related surgical interventions. The purpose of this work is to predict and evaluate the LOS value using machine learning methods and applying multiple linear regression, starting from clinical data of patients hospitalized with lower limb fractures. The data were collected at the "San Giovanni di Dio e Ruggi d'Aragona" hospital in Salerno (Italy).

Implementation of a Dedicated Orthopaedic Trauma Room in Hip and Femur Fracture Care: A 17-Year Analysis

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on hip and femur fracture care.

DESIGN

A retrospective cohort study. Setting: Level 1 trauma center. Patients: 2928 patients with femoral neck, pertrochanteric, and femoral shaft and distal femur (FSDF) fractures.

INTERVENTION

Implementation of a DOTR.

MAIN OUTCOME MEASURES

Hospital length of stay (LOS), emergency department (ED) LOS, intensive care unit (ICU) LOS, and time to operating room (TTOR).

RESULTS

Implementation of a DOTR resulted in significant improvement in TTOR for all patient groups ( P < 0.05). We found shorter TTOR for pertrochanteric ( P < 0.001), femoral neck ( P = 0.039), and FSDF groups ( P = 0.046). Total hospital LOS was shorter for patients with pertrochanteric ( P < 0.001) and femoral neck fractures ( P = 0.044). Patients with pertrochanteric hip fractures demonstrated shorter ICU LOS ( P < 0.001). No LOS improvements were observed among patients in the FSDF group. ED LOS was significantly longer in all patient groups ( P < 0.001).

CONCLUSIONS

Implementation of a DOTR was associated with shorter TTOR, shorter hospital and ICU LOS, and longer ED LOS. There was a greater number of patients transferred into the investigating institution and fewer patients transferred out. These data support the utility of a DOTR as it relates to an improvement in hospital stay-related outcomes in patients with fractures of the hip and femur. Our results suggest that a DOTR in a Level I trauma hospital is associated with improvement in patient care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review

IMPORTANCE

Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors.

OBJECTIVE

To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS.

EVIDENCE REVIEW

A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.

FINDINGS

Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements.

CONCLUSIONS AND RELEVANCE

In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

Advantages of a Dedicated Orthopaedic Trauma Operating Room for Diaphyseal Femur Fractures

OBJECTIVE

To examine the impact of instituting a dedicated orthopaedic trauma operating room (DOTOR) at a Level I trauma center on diaphyseal femur fracture management.

DESIGN

Retrospective cohort study.

SETTING

Regional, university-based Level I trauma center.

PATIENTS

Trauma patients 18-65 years of age who presented between October 2016 and December 2018 (approximately 1 year before and after implementation of the DOTOR) and underwent surgery for diaphyseal femur fractures. One hundred twenty-eight patients met eligibility criteria for inclusion: 60 were treated before and 68 after implementation of the DOTOR.

INTERVENTION

Implementation of a DOTOR in October 2017.

MAIN OUTCOME MEASURES

Percentage of external fixation versus intramedullary nailing, time from emergency department visit to definitive fixation, duration of surgery, and hospital length of stay.

RESULTS

The only significant difference in patient demographics between the before and after groups was mechanism of injury (P = 0.003). Percentage of external fixators as an initial procedure decreased from 15% to 2.9% (P = 0.024). Time to definitive fixation with intramedullary nail decreased from 1083 minutes to 659 minutes (P = 0.002). There was no significant change in median operative time of intramedullary nailing (P = 0.573). Although not statistically significant, hospital length of stay decreased from 7 days to 5.5 days after implementation (P = 0.158). Cost analysis revealed annual cost savings of more than $261,678 for diaphyseal femur fractures alone by implementing a DOTOR.

CONCLUSIONS

For diaphyseal femur fractures, instituting a DOTOR at a Level I trauma center reduced the percentage of patients requiring a 2-stage fixation, reduced the time to definitive fixation, and yielded cost savings.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of a 6 am-9 am Dedicated Orthopaedic Trauma Room on Hip Fracture Outcomes in a Community Level II Trauma Center

OBJECTIVE

To assess the outcomes of elderly hip fracture surgeries performed 12 months before and 12 months after the implementation of a daily 6 am-9 am dedicated orthopaedic trauma room (DOTR) at a Level II community trauma center.

DESIGN

Retrospective cohort study.

SETTING

Level II academic trauma center.

PATIENTS

A total of 431 consecutive trauma patients undergoing surgical management of isolated low-energy hip fractures from January 1, 2018, to December 31, 2019.

INTERVENTION

Implementation of a 6 am-9 am DOTR Monday through Friday.

MAIN OUTCOME MEASURES

Time to surgery, number of cases performed after hours, surgical time, 90-day morbidity and mortality, and time to therapy.

RESULTS

Retrospective analysis showed that despite a 24% increase in surgical hip fracture volume, implementation of a part-time DOTR led to a decrease in after-hours surgery (32.4% vs. 19.6%; P = 0.008) and patients requiring the intensive care unit postoperatively (7% vs. 3.8%; P = 0.036). Surgeries performed after hours were longer than that of surgeries performed during the daytime (82.0 vs. 68 minutes; P = 0.003) and had more complications (pneumonia, pulmonary embolism, and surgical site infection; P = 0.002, 0.047, 0.024, respectively).

CONCLUSIONS

Our results show that a part-time DOTR in a community Level II hospital is associated with improvement in patient care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient outcomes in Tropical North Queensland after implementation of a dedicated orthopaedic trauma list

BACKGROUND

To assess patient outcomes after the introduction of a regular orthopaedic-specific trauma list (OTL).

METHODS

A retrospective analysis of 422 trauma cases was performed comparing patient outcomes after the introduction of the OTL. Four common traumatic injuries requiring operative intervention were considered; closed tibial fractures, intra-capsular neck of femur fractures, displaced paediatric supracondylar humeral fractures and hand tendon injuries. The outcomes assessed included time from patient referral to theatre, time from admission to theatre, operative times, time of day operation commenced, consultant involvement, hospital length of stay (LOS), returns to theatre and mortality.

RESULTS

Tibial fractures had an increased time from admission to theatre (0.46 days pre-OTL versus 1.21 days post-OTL, P = 0.01), hand tendons injuries had an increase in time from referral to theatre (1.06 days pre-OTL versus 2.82 days post-OTL, P = 0.001). Consultant involvement increased for supracondylar procedures (27% pre-OTL versus 61% post-OTL, P < 0.001) and tendinous hand injury repairs (5% pre-OTL versus 37% post-OTL, P < 0.001). There was a decrease in cases starting after 17:00 hours; however, no group reached statistical significance. There was a reduction in complications and shorter inpatient LOS, however; these were not statistically significant. There was no difference in overall operative times after OTL implementation; however, individual group differences existed between registrars and consultants.

CONCLUSION

Implementing regular orthopaedic trauma lists resulted in greater consultant involvement and was associated with decreased after-hours operating. Delays to theatre increased from both time of referral and admission; however, this was not correlated with increases in significant harm.

Hip fracture patients admitted to hospital on weekends are not at increased risk of 30-day mortality as compared with weekdays

Background

Hip fractures remain a major health concern owing to the increasing elderly population and their association with significant morbidity and mortality. The effects of weekend admission on mortality have been studied since the late 1970s. Despite most studies showing that mortality rates are higher for patients admitted on a weekend, the characteristics of the admitted patients have remained unclear. We aim to investigate this ‘weekend effect’ at our hospital in patients presenting with a hip fracture.

Methods

Patients undergoing acute hip fracture surgery were identified from the local National Hip Fracture Database. Patient demographics, fracture type, co-morbidities and admission blood parameters were examined. The outcome analysed was 30-day mortality. The data were analysed with regard to day of admission, i.e. weekday (Monday to Friday) or weekend (Saturday and Sunday).

Results

A total of 894 patients were included. Results demonstrated that 30-day mortality was similar on the weekend compared with the weekday (6.96% versus 10.39%, OR 0.65, 95% CI 0.36–1.14, p = 0.128) for patients who sustained an acute hip fracture. The total number of deaths within 30 days was 85 (69 weekday versus 16 weekend). This remained non-significant after adjusting for several variables: age and sex only (OR = 0.65, 95% CI 0.37–1.16, p = 0.146), age, sex, and care variables (OR = 0.59, 95% CI 0.33–1.06, p = 0.080), age, sex, and blood test results (OR = 0.62, 95% CI 0.35–1.12, p = 0.111), and all covariates (OR = 0.69, 95% CI 0.29–1.62, p = 0.392). In the fully adjusted model, the following variables were independent predictors of mortality: sex (male) (OR = 1.93, 95% CI 1.11–3.35, p = 0.019) and ASA > 2 (OR = 2.6, 95% CI 1.11–6.11, p = 0.028) and age (1.08, 95% CI 1.04–1.13, p < 0.001).

Conclusion

The evidence for a ‘weekend effect’ in patients with a hip fracture is absent in this study. However, we have shown other factors that are associated with increased mortality such as increased age, male sex and higher ASA grade.

Level of evidence

Level 3.

The Dedicated Orthopaedic Trauma Room Model: Adopting a New Standard of Care

The dedicated orthopaedic trauma room (DOTR) has emerged over the last decade as an effective approach to improving workflow while reducing the complications and costs that are associated with musculoskeletal trauma care. We surveyed the top 20 hospitals in the United States and found that 14 (70%) utilize a DOTR. Coupled with recent data on improved outcomes and patient flow, we see evidence that the availability of a DOTR has become a best practice for orthopaedic trauma care.

Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort

Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ± 7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Symptomatic pulmonary embolism following hip fracture: A nationwide study

INTRODUCTION

This study evaluated the incidence of symptomatic pulmonary embolism (PE), subsequent mortality, risk factors, and the effects of pharmacological thromboprophylactic intervention following hip fracture surgery in Taiwan.

MATERIALS AND METHODS

A nationwide study was conducted from February 2004 to September 2013. Hip fracture patients were placed into two groups: without symptomatic PE (control group) and with symptomatic PE (PE group). We analyzed the incidence of and risk factors for symptomatic PE, post-operative mortality rate, and effects of pharmacological thromboprophylactic intervention.

RESULTS

We identified 165,748 hip fracture patients. The 3-month cumulative incidence of post-operative symptomatic PE was 0.24% (n = 392). The cumulative 1-, 3-, and 6-month mortality rates were significantly higher in the PE group (16.1%, 23.0%, and 28.6%, respectively) than in the controls (3.3%, 6.7%, and 10.2%, respectively). Increased risk of post-operative symptomatic PE was associated with prior history of PE (adjusted odds ratio [OR], 40.00; 95% CI, 24.75-64.67; P < 0.001), female sex (adjusted OR, 1.33; 95% CI, 1.07-1.65; P = 0.009), older age (>75 years) (adjusted OR, 1.51; 95% CI, 1.20-1.91; P < 0.001), and hemiarthroplasty (adjusted OR, 1.23; 95% CI, 1.01-1.51; P < 0.043). Pharmacological thromboprophylaxis significantly reduced the incidence of post-operative PE (adjusted hazard ratio, 4.54; 95% CI, 2.08-9.88; P < 0.001).

CONCLUSIONS

The incidence of symptomatic PE after hip fracture surgery was not low in Asian patients, and PE significantly decreased patient survival rates. Some groups were at higher risk for PE; in these instances, thromboprophylaxis, prompt diagnosis, and subsequent intervention are advised.

Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference?

OBJECTIVE

To assess the "Dedicated Orthopaedic Trauma Operating Room" (DOTOR) effect on management and outcomes of open tibia and femur fractures.

DESIGN

Retrospective chart review.

LOCATION

University Level I Trauma Center.

METHODS

Patients categorized into those managed in the DOTOR versus those managed in a standard on-call operating room (OCOR). Data collected include patient and injury characteristics, time to debridement, and patient outcomes.

RESULTS

A total of 297 patients with 347 open tibia and femur fractures were included; 154 patients (174 fractures) were managed in the DOTOR group and 143 patients (170 fractures) were managed in the OCOR group. The average time to debridement was significantly longer for DOTOR (12.9 hours) versus OCOR (5.4 hours). The DOTOR group was 9 times less likely to undergo debridement within 6 hours. The number of patients debrided within 24 hours was similar (90% for DOTOR vs. 96% OCOR). The rate of primary fracture union was significantly higher in the DOTOR (73.2% vs. 56.6%). OCOR patients were twice as likely to have an unplanned surgery. Rates of infection, nonunion, and amputation were similar.

CONCLUSION

Despite earlier access to the Operating room for debridement in the OCOR group, there was no difference in the infection rate compared with the DOTOR group. However, patients managed in the DOTOR group were more likely to go on to uncomplicated fracture union and less likely to have an unplanned surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Operational strategies to manage non-elective orthopaedic surgical flows: a simulation modelling study

OBJECTIVES

To explore the value of simulation modelling in evaluating the effects of strategies to plan and schedule operating room (OR) resources aimed at reducing time to surgery for non-elective orthopaedic inpatients at a Swedish hospital.

METHODS

We applied discrete-event simulation modelling. The model was populated with real world data from a university hospital with a strong focus on reducing waiting time to surgery for patients with hip fracture. The system modelled concerned two patient groups that share the same OR resources: hip-fracture and other non-elective orthopaedic patients in need of surgical treatment. We simulated three scenarios based on the literature and interaction with staff and managers: (1) baseline; (2) reduced turnover time between surgeries by 20 min and (3) one extra OR during the day, Monday to Friday. The outcome variables were waiting time to surgery and the percentage of patients who waited longer than 24 hours for surgery.

RESULTS

The mean waiting time in hours was significantly reduced from 16.2 hours in scenario 1 (baseline) to 13.3 hours in scenario 2 and 13.6 hours in scenario 3 for hip-fracture surgery and from 26.0 hours in baseline to 18.9 hours in scenario 2 and 18.5 hours in scenario 3 for other non-elective patients. The percentage of patients who were treated within 24 hours significantly increased from 86.4% (baseline) to 96.1% (scenario 2) and 95.1% (scenario 3) for hip-fracture patients and from 60.2% (baseline) to 79.8% (scenario 2) and 79.8% (scenario 3) for patients with other non-elective patients.

CONCLUSIONS

Healthcare managers who strive to improve the timelines of non-elective orthopaedic surgeries may benefit from using simulation modelling to analyse different strategies to support their decisions. In this specific case, the simulation results showed that the reduction of surgery turnover times could yield the same results as an extra OR.

A Dedicated Orthopaedic Trauma Operating Room Improves Efficiency at a Pediatric Center

BACKGROUND

Dedicated orthopaedic trauma operating rooms have improved operating room efficiency, physician schedules, and patient outcomes in adult populations. The purpose of this study was to determine if a dedicated orthopaedic trauma operating room was associated with improved patient flow and cost savings at a level-I pediatric trauma center.

METHODS

A retrospective analysis was performed for two 3-year intervals before and after implementation of a weekday, unbooked operating room reserved for orthopaedic trauma cases. Index procedures for 5 common fractures were investigated, including supracondylar humeral fractures, both bone forearm fractures, lateral condylar fractures, tibial fractures, and femoral fractures. To provide a control group to account for potential extrinsic changes in hospital efficiency, laparoscopic appendectomies were also analyzed. For each procedure, efficiency parameters and surgical complications, defined as unplanned reoperations, were compared between time periods. The mean cost reduction per patient was calculated on the basis of the mean daily cost of an inpatient hospital bed.

RESULTS

Of 1,469 orthopaedic procedures analyzed, 719 cases occurred before the implementation of the dedicated orthopaedic trauma operating room, and 750 cases were performed after the implementation. The frequency of after-hours procedures (5 P.M. to 7 A.M.) was reduced by 48% (p < 0.001). The mean wait time for the operating room decreased among supracondylar humeral fractures, lateral condylar fractures, and tibial fractures, whereas no significant decrease (p = 0.302) occurred among 2,076 laparoscopic appendectomy cases. The mean duration of the surgical procedure and the mean time in the operating room were not significantly affected. Across all orthopaedic procedures, the mean duration of inpatient hospitalization decreased by 5.6 hours (p < 0.001), but no significant difference occurred among appendectomies. Decreased length of stay resulted in a mean cost reduction of $1,251 per patient. Supracondylar humeral fracture cases performed after implementation of the dedicated orthopaedic trauma operating room had fewer surgical complications (p = 0.018). No difference in complication rate was detected among the other orthopaedic procedures.

CONCLUSIONS

A dedicated orthopaedic trauma operating room in a pediatric trauma center was associated with fewer after-hours procedures, decreased wait time to the surgical procedure, reduced length of hospitalization, and decreased cost.

Higher Charlson Comorbidity Index Scores Are Associated With Increased Hospital Length of Stay After Lower Extremity Orthopaedic Trauma

OBJECTIVES

The purpose of this study was to explore the relationship between preoperative Charlson Comorbidity Index (CCI) and postoperative length of stay (LOS) for lower extremity and hip/pelvis orthopaedic trauma patients.

DESIGN

Retrospective.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 1561 patients treated for isolated lower extremity and pelvis fractures between 2000 and 2012.

INTERVENTIONS

Surgical intervention for fractures MAIN OUTCOME MEASUREMENTS:: The main outcome metric was LOS. Negative binomial regression analysis was used to examine the association between CCI and LOS while controlling for significant confounders.

RESULTS

One thousand five hundred sixty-one patients met the inclusion criteria, 1302 (83.4%) of which had lower extremity injuries and 259 (16.6%) experienced hip/pelvis trauma. A total of 1001 (64.1%) patients presented with a CCI score of 1 and stayed an average of 7.9 days. Patients with a CCI of 3 experienced a mean LOS of 1.2 days longer than patients presenting with a CCI of 1, whereas patients presenting with a CCI score of 5 stayed an average of 4.6 days longer. After controlling for age, race, American Society of Anesthesiologists score, sex, anesthesia type, and anesthesia time, a higher preoperative CCI was found to be associated with longer LOS for patients with lower extremity fractures (Incidence Rate Ratio: 1.04, P = 0.01). No significant association was found between CCI and LOS for patients with hip/pelvic fractures.

CONCLUSIONS

This study demonstrated the potential utility of the CCI as a predictor of hospital LOS for lower extremity patients; however, the association may be small given the smaller Incidence Rate Ratio value. Further studies are needed to clarify the predictive value of the CCI for different types of orthopaedic injuries.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete.

When is the ideal time to operate on a patient with a fracture of the hip?

Fractures of the hip are common, often occurring in frail elderly patients, but also in younger fit healthy patients following trauma. They have a significant associated mortality and major social and financial implications to patients and health care providers. Many guidelines are available for the management of these patients, mostly recommending early surgery for the best outcomes. As a result, healthcare authorities now put pressure on surgical teams to ‘fast track’ patients with a fracture of the hip, often misquoting the available literature, which in itself can be confusing and even conflicting.

This paper has been written following an extensive review of the available literature. An attempt is made to clarify what is meant by early surgery (expeditious versus emergency), and we conclude with a personal view for the practical management of these patients of variable age, fitness and type of surgery performed within services that are often under considerable pressure of finance and available operating theatres and qualified staff.

Cite this article: Bone Joint J 2016;98-B:1573–81.

Patient preferences for emergency or planned hip fracture surgery: a cross-sectional study

BACKGROUND

The ideal timing of surgical management for hip fractures remains controversial. Currently, individual surgeon preference and departmental resources guide decision making regarding the use of emergency or planned operating lists for hip fracture surgery. We evaluated patient preference for emergency or planned surgery.

METHODS

102 patients awaiting surgery for a hip fracture at a tertiary hospital were surveyed in this cross-sectional study. After being informed of the benefits and risks associated with an emergency or planned operation, the patients were asked to indicate a hypothetical preference for surgical operating time. They were then asked to give an importance value for six factors that may influence decision making including consultant supervision, operative timeliness, surgical cancellation, after hours operation, length of hospital stay and repeated fasting. For each factor, absolute importance was rated from 0 to 10, and factors were independently ranked for relative importance from 1 to 6. An open ended question was used to include any other factors they thought relevant to their hypothetical decision making.

RESULTS

Of the 102 patients surveyed, 95 patients (93 %) indicated that they preferred planned over emergency surgery. The most important influencing factor was the presence of specialist supervision (mean rating 9.4, mean rank 1.3) followed by avoidance of operative cancellation (mean rating 8.8, mean rank 2.3) and avoidance of after hours operations (mean rating 8.1, mean rank 3.2). A lower importance was attached to operative timeliness and avoiding prolonged fasting, with reduction in length of hospital stay being the least important variable. There was a direct correlation between absolute ratings and relative rankings independently assigned by patients to each factor.

CONCLUSIONS

Patients with hip fractures prefer planned rather than emergency surgery, the presence of specialist supervision being the most important factor influencing their preference.

Preliminary results of an early vs delayed timing of surgery in the management of proximal femur fragility fractures

INTRODUCTION

The appropriate surgical timing for the treatment of proximal femur fractures is still debated. Advantages of a delayed surgery may be: stabilization of systemic diseases, decrease of the risk of perioperative mortality and morbidity. An early timing of surgery may allow: early mobilization, reduction of the risks of disability and hospital stays, early return to home of the patients. However, the effects on mortality are still discussed.

PURPOSE

The purpose of this study is to assess the influence of the surgical timing on clinical outcomes, complications, and mortality in a preliminary experience of the early management of these fractures vs the delayed surgery.

METHODS

A series of 176 patients was retrospectively evaluated. 132 patients were followed-up for one year after surgery. The evaluation was performed by the assessment of the comorbidities, preoperative wait for surgery, type of fracture and procedures, hospital stay, and functional outcomes: 33 patients were operated with an early timing, 99 with a delayed surgery.

RESULTS

The mean mortality rate was 18.2% in the early timing (6/33 patients), and 23.2% in the delayed timing (23/99 patients): no significant difference was recorded in the preliminary analysis. Postoperative complications were recorded in 28 patients (21.2%): 4 patients were operated within 48 hours (12.1%) and 24 after 48 hours (24.2%) with no substantial differences. The postoperative hospital stay showed no correlation with the timing of surgery, as no evidence was found on the functional recovery and postoperative disability.

CONCLUSIONS

No significant differences were found on the evaluated parameters in the two groups in the present preliminary study. A correlation between male sex and mortality, and male sex and postoperative complications was assessed. An enlargement of the study population is needed to surely clarify any effective differences, given the fact that recent studies seem to identify in the early treatment the better strategy to ensure the best recovery and the lower rate of mortality and complications.

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike

OBJECTIVE

Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule.

DESIGN

Retrospective case-control study.

SETTING

Level 1 academic trauma center.

PATIENTS

A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures.

INTERVENTION

Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF).

MAIN OUTCOME MEASURES

Surgical timing, intervention type, perioperative complications, and postoperative length of stay.

RESULTS

Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM-7:30 AM) for all femoral neck fractures (66.7%-19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04).

CONCLUSIONS

In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does a Dedicated Unit for the Treatment of Hip Fractures Improve Acute Outcomes?

The aim of this study is to establish whether management of patients in a unit dedicated to the treatment of hip fractures improves acute outcomes. We prospectively studied 300 patients with hip fractures in two separate groups. Patients in Group 1 were operated on in a mixed trauma unit and recovered in a traditional trauma ward. Patients in Group 2 were operated on in dedicated theatres and recovered in a unit which catered exclusively for hip fractures. The ages, ASA grades, and type of procedure performed in the two groups were comparable. The 30-day mortality rate in Group 2 was 9% as opposed to 12% in Group 1 (P = 0.34). The inpatient length of stay was significantly lower in Group 2 (18 days versus 25 days; P = 0.0002) and so was the time taken to operate (28 hours versus 34 hours; P = 0.04). A greater percentage of patients in Group 2 were discharged home as opposed to a nursing home (75% versus 67%). This difference approached significance (P = 0.18). We conclude that prioritisation and prompt management of patients with hip fractures in a dedicated unit significantly improve time to surgery and significantly decrease length of stay.

Impact of multidisciplinary hip fracture program on timing of surgery in elderly patients

The effect of patient characteristics and organizational and system factors on time to surgery were studied using Emilia Romagna Region database and hospital survey. The results showed that the implementation of a Hip Fracture Program significantly increased the probability of early surgery while single intervention had only slight effect

INTRODUCTION

The purpose of this study is to evaluate the effect of formal Hip Fracture Program (HFP) on timing of surgery in hip fracture older patients.

METHODS

This is a retrospective cohort study based on Emilia Romagna administrative databases. Data on organizational and system factor were also obtained through a hospital survey. A multilevel logistic regression analysis was carried out to assess the effect of covariates on early surgery, taking into account patient level, hospital level, and trust level variability.

RESULTS

From 1 January to 31 December 2011, 5,520 subjects over 65 years old underwent surgical repair for hip fracture in Emilia Romagna. The mean waiting time to surgery was 3.4 ± 12.3 days, and the overall percentage of patients operated within 2 days was 52.2%. In the adjusted multilevel logistic model, significant risk factors affecting the timing of surgical intervention at patient level were age, comorbidity, day of admission, and antiplatelet or warfarin therapy while no significant single variables were found at hospital level including dedicated operation theater, hospital volume, dedicated orthogeriatric beds, and geriatrician involvement. The most significant variable was the implementation of HFP at trust level that increased three times the probability of early surgery after adjusting for confounding variables (OR 3.216, 95% CI 0.582-6.539).

CONCLUSIONS

Several modifiable organizational factors may affect the proportion of patients with hip fracture undergoing early surgery. This study suggests that the development and the implementation of an evidence-based HFP at trust level are a key point of the strategy of quality of care.

The management of hip fracture in the older population. Joint position statement by Gruppo Italiano Ortogeriatria (GIOG)

This document is a Joint Position Statement by Gruppo Italiano di OrtoGeriatria (GIOG) supported by Società Italiana di Gerontologia e Geriatria (SIGG), and Associazione Italiana Psicogeriatria (AIP) on management of hip fracture older patients. Orthogeriatric care is at present the best model of care to improve results in older patients after hip fracture. The implementation of orthogeriatric model of care, based on the collaboration between orthopaedic surgeons and geriatricians, must take into account the local availability of resources and facilities and should be integrated into the local context. At the same time the programme must be based on the best available evidences and planned following accepted quality standards that ensure the efficacy of the intervention. The position paper focused on eight quality standards for the management of hip fracture older patients in orthogeriatric model of care. The GIOG promotes the development of a clinic database with the aim of obtaining a qualitative improvement in the management of hip fracture.

Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To describe the impact of patient demographics, injury-specific factors, and medical co-morbidities on outcomes after hip fracture using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB).

METHODS

The 2008 NSP-NTDB was queried to identify patients sustaining hip fractures. Patient demographics, co-morbidities, injury-specific factors, and outcomes (including mortality and complications) were recorded and a national estimate model was developed. Unadjusted differences for risk factors were evaluated using t test/Wald Chi square analyses. Weighted logistic regression and sensitivity analyses were performed to control for all factors in the model.

RESULTS

The weighted sample contained 44,419 incidents of hip fracture. The average age was 72.7. Sixty-two percent of the population was female and 80 % was white. The mortality rate was 4.5 % and 12.5 % sustained at least one complication. Seventeen percent of patients who sustained at least one complication died. Dialysis, presenting in shock, cardiac disease, male sex, and ISS were significant predictors of mortality, while dialysis, obesity, cardiac disease, diabetes, and a procedure delay of ≥2 days influenced complications. The major potential modifiable risk factor appears to be time to procedure, which had a significant impact on complications.

CONCLUSIONS

This is the first study to postulate predictors of morbidity and mortality following hip fracture in a US national model. While many co-morbidities appear to be influential in predicting outcome, some of the more significant factors include the presence of shock, dialysis, obesity, and time to surgery.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Complications and their risk factors following hip fracture surgery

PURPOSE. To evaluate various postoperative complications and their risk factors in hip fracture patients. METHODS. 207 female and 87 male consecutive patients (mean age, 78.1 years) who underwent surgical (n=242) or conservative (n=52) treatment for closed fractures of the femoral neck (n=157) or peritrochanter (n=137) were prospectively studied. The types of complication and outcome were recorded. The comorbidity status of the patients was categorised based on the American Society of Anesthesiologists (ASA) classification. Complications and their associations with various risk factors and mortality were analysed. RESULTS. For all patients, the mean length of hospitalisation was 14.6 days. For the 242 patients who underwent surgical treatment after a mean of 3.6 days, 56.8% of them had at least one complication. Acute urinary retention (39.3%) and urinary tract infection (24.0%) were most common. Patients with ASA grade III or higher had 2.3 fold higher risk of developing complications than those with lower-grade comorbidity, whereas patients with delayed operation (>48 hours after presentation) had 1.8 fold higher risk of developing complications than those without delayed operation. Four patients died in hospital: 2 from myocardial infarction and 2 from upper gastrointestinal bleeding. CONCLUSION. Complications after hip fracture surgery were common. Advanced age, high ASA status, and delay in surgery were associated with higher complication rates. Operations should be performed on medically fit patients as early as possible.

The dedicated orthopedic trauma operating room

The development and implementation of a dedicated orthopedic trauma operating room (OTOR) that is used for the treatment of orthopedic trauma patients has changed and improved the practice of orthopedic trauma surgery. Advantages noted with OTOR implementation include improvements in morbidity and complication rates, enhancements in the professional and personal lifestyles of the on-call surgeon, and increased physician recruitment and retention in orthopedic traumatology. However, the inappropriate use of the OTOR, which can waste valuable resources and delay the treatment of emergent cases, must be monitored and avoided.

Ward-based rather than team-based junior surgical doctors reduce mortality for patients with a fracture of the proximal femur: results from a two-year observational study

We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox's regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in Clostridium difficile colitis (p = 0.017), deep wound infection (p = 0.043) and gastrointestinal haemorrhage (p = 0.033). There were no differences in any patient risk factors (except the prevalence of chronic obstructive pulmonary disease), cause of death and length of stay before and after intervention. The underlying mechanisms are unclear, but may include improved efficiency and medical contact time. These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect.

Does timing of surgery matter in fragility hip fractures?

The effect of delay of surgery on the geriatric hip fractures has been a subject of interest in the past two decades. While the elderly patients will not tolerate long periods of immobilization, it is still unclear how soon these surgeries need to be performed. A review of existing literature was performed to examine the effect of timing of surgery on the different outcome parameters of these patients. Although there is conflicting evidence that early surgery would improve mortality, there is widespread evidence in the literature that other outcomes including morbidity, the incidence of pressure sores, and the length of hospital stay could be improved by shortening the waiting time of hip fracture surgery. We concluded that it is beneficial to the elderly patients to receive surgical treatment as an urgent procedure as soon as the body meets the basic anesthetic requirements.

Symptomatic venous thromboembolism following a hip fracture

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE) remains a substantial cause of morbidity and mortality following hip fracture. Previous work has not identified any risk factors associated with the type of hip fracture. We report the incidence of and risk factors for development of symptomatic VTE in patients following a hip fracture.

PATIENTS AND METHODS

In this prospective study, we collected information on 5,300 consecutive patients who were admitted to a single unit with a hip fracture-in terms of their pre-admission status, details of any operation performed, and details of complications in the form of symptomatic venous thromboembolism. All patients received thromboprophylaxis with heparin.

RESULTS

The incidence of symptomatic VTE was 2.2% (95% CI: 1.8-2.6). 85% of these events occurred within 5 weeks of the fracture. The statistically significant risk factors for symptomatic VTE were better preoperative mobility, living in one's own home, high mental test score, high preoperative hemoglobin, inter-trochanteric fractures, and fixation with a dynamic hip screw. In multivariate analysis adjusting for sex and age, type of residence on admission, type of fracture, and hemoglobin values on admission remained independently significant.

INTERPRETATION

We found that the rate of symptomatic VTE using thromboprophylaxis with heparin was low but that there were a number of groups that were at a significantly higher risk of developing VTE. The patients who are particularly at risk appear to be those with a subtrochanteric or intertrochanteric hip fracture; here, the incidence of symptomatic VTE was twice that of intracapsular hip fractures.

Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients

In order to define the optimum timing of surgery for a hip fracture, we performed a systematic review of published evidence. Data was extracted by two independent reviewers and the methodology of each study was assessed. Fifty-two studies involving 291,413 patients were identified. Outcomes measured were mortality, post-operative complications, length of hospital stay and percentage of patients discharged home. We found no randomised trials. For the 25 studies involving 282,470 participants that undertook adjustment for confounding factors, early surgery was associated with a reduced hospital stay. These studies produced conflicting results regarding mortality and morbidity being increased or unaffected by delaying surgery. None of these studies reported any adverse outcomes for early surgery. Those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. In conclusion early surgery (within 48h of admission) after a hip fracture reduces hospital stay and may also reduce complications and mortality.

Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?

INTRODUCTION

Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival.

PATIENTS AND METHODS

The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit.

RESULTS

A total of 883 patients were included in the audit (35-126 per hospital). Overall, 5-15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5-19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09).

CONCLUSIONS

Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.

Management of open fractures in pediatric patients: current teaching in Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs

The purpose of this study was to determine the method of treatment for open fractures in pediatric patients that is used and taught at academic orthopedic residency programs. A web-based survey was constructed and emailed to program directors of orthopedic residencies. Seventy programs out of a total of 140 surveyed programs responded. Data were tabulated and charts created in an Excel spreadsheet. Type I fractures were treated by most with a cephalosporin alone (97%) for less than 48 h (87%). Type II were treated by most programs with a cephalosporin alone with no aminoglycoside (84%) for less than 48 h (80%). Type IIIa were treated by most programs with a cephalosporin and an aminoglycoside (50%) for less than 48 h (60%). Type IIIb were treated by most programs with a cephalosporin and aminoglycoside (54%) for less than 48 h (53%). Type IIIc were also treated by most with a cephalosporin and an aminoglycoside (53%) for less than 48 h (51%). Wounds were closed by most responders for type I (90%), type II (86%) and type IIIa (50%) but not type IIIb (10%), and type IIIc (16%). For the programs responding to the pediatric section of the survey over half (53%) reported using a trauma room and 58% reported allowing residents to irrigate and debride wounds in the emergency room. In conclusion, for pediatric patients most orthopedic residencies use a cephalosporin alone for type I and type II open fractures with an aminoglycoside added for type III fractures. Treatment is typically for 48 h or less. Delay of 6 h seems to be accepted for type I and type II fractures but not type III fractures.

Proximale Femurfrakturen im Alter

BACKGROUND

The section of geriatric trauma ("AG-Alterstraumatologie") of the "Deutsche Gesellschaft für Unfallchirurgie" (DGU) and the "Lohmann & Birkner Health Care Consulting GmbH" in co-operation with the health insurance funds (VdAK and AEV) supplied the relevant data of approximately 23 million insured persons from the years 2002 to 2004.

METHODS

All data from patients over the age of 60 staying in hospital because of proximal femur fractures and without further injuries as the main diagnosis were extracted from the available amount of data and then analysed. There were 68,929 (9.5%) cases diagnosed with proximal femur fractures of 724,606 patients treated in hospital.

RESULTS

There was a significant age-dependent increase in incidents of proximal femur fractures with a maximum of 3,000 injuries around the age of 82 years. The surgical treatment of proximal femur fractures was carried out with a joint-preserving stabilising method (osteosynthesis-screws-"DHS"-nailing systems) in 49.5%, with endoprosthesis in 48.6 % as well as other methods in 1.9% of the cases. In comparison to hip replacement care, a shorter hospital stay could be proved with osteosynthetic methods.