Patient and hospital-level factors associated with time to surgery after hip fracture in Ireland: Analysis of national audit data 2016–2020

IntroductionIn hip fracture care, time to surgery (TTS) is a commonly used quality indicator associated with patient outcomes including mortality. This study aimed to identify patient and hospital-level characteristics associated with TTS in Ireland.MethodsNational data from the Irish Hip Fracture Database (IHFD) (2016–2020) were analysed along with hospital-level characteristics obtained from a 2020 organisational survey. Generalised linear model regression was used to explore the association of TTS with case-mix, surgical details, hospital-level staffing and specific protocols recommended to expedite surgery.ResultsA total of 14,951 patients with surgically treated hip fracture from 16 hospitals were included (Mean age= 80.6 years (SD=8.8), 70.4% female). Mean TTS was 40.9 h (SD=60.3 h). Case-mix factors associated with longer TTS were male sex and higher American Society of Anaesthesiologists (ASA) grade. Other factors found to be associated with longer TTS included low pre-morbid mobility, inter-hospital transfer, weekday presentation, pre-operative medical physician assessment, intracapsular fracture type, arthroplasty surgery, general anaesthesia, consultant grade of surgeon and lower hospital-level orthopaedic surgical capacity. The oldest age-group and pre-fracture nursing home residence were associated with shorter TTS when adjusted for other case-mix factors. None of four explored protocols for expediting surgery were associated with TTS.ConclusionPatients with more comorbidity experience longer surgical delay after hip fracture in Ireland, in line with international research. Low availability of senior orthopaedic surgeons in Ireland may be delaying hip fracture surgery. Pathway of presentation, including via inter-hospital transfer or hospital bypass, is an important factor that requires further exploration. Further research is required to identify successful system-level protocols and interventions that may expedite hip fracture surgery within this setting.     

Concomitant hip and upper extremity fracture in elderly patients: Prevalence and clinical implications

BackgroundHip fracture and upper extremity fracture are most important age-related fracture. However, there have been few reports about the analysis of prevalence or risk factors with concomitant hip and upper extremity fractures. This study aimed to describe the prevalence and clinical implications of the concomitant hip and upper extremity fractures in elderly.MethodsWe evaluate 1018 patients aged >65 years who were surgically treated for femoral neck or intertrochanteric fractures between March 2008 and December 2018. 35 patients (3.4%) with a hip fracture combined upper extremity fracture. All patients were classified into the isolated hip fracture and the concomitant fracture. We analyzed these patients’ characteristics such as age, gender, bone mineral density (BMD), body mass index (BMI), Korean version of Mini-Mental State Examination (MMSE-K), injury mechanism, and length of hospital stay.ResultsThe most common site of upper extremity fracture was distal radius fracture of 15 patients (42.8%), followed by proximal humeral fracture of 8 (22.8%). Concomitant fractures occurred on the same side in 30 patients (85.7%). The mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p < 0.05). Mean preinjury MMSE-K was 22.7 in isolated hip fracture and 25.6 in concomitant fracture patients (p < 0.05). Mean length of hospital stay was statistically significant different between two groups (p < 0.05). According to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture.ConclusionWe found a 3.4% prevalence of concomitant hip and upper extremity fractures. It was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. In addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation.     

Cement augmentation for trochanteric fracture in elderly: A systematic review

BackgroundCement augmentation of internal fixation of hip fracture has reported to improve fracture stability in osteoporotic hip fractures, reducing the risk of cut-out of the sliding screw through the femoral head. The purpose of present study was to perform a systematic literature review on the effects of augmentation technique in patients with osteoporotic hip fractures.Material and methodsA comprehensive literature search was systematically performed to evaluate all papers published in English language included in the literature between January 2010 and July 2020, according to the PRISMA 2009 guidelines. In vivo and in vitro studies, case reports, review articles, cadaveric studies, biomechanical studies, histological studies, oncological studies, technical notes, studies dealing with radiological classifications and studies on revision surgery were excluded.ResultsA total of 5 studies involving 301 patients were included. Patients had a mean age of 84.6 years and were followed up for a mean period of 11 months. The proximal femoral fractures were stabilized with implantation of the PFNA or Gamma nail and augmentation was performed with two different cements: polymethylmethacrylate (PMMA) in 4 studies and calcium phosphate (CP) in one study. Overall, 57.5% of patients reached the same or greater preoperative mobility, and postoperative Parker Mobility Score and Harris Hip Score were acceptable. No significantly complications were observed, and no additional surgery related to the implant was required.ConclusionThe results of this systematic review show that cement augmentation is a safe and effectiveness method of fixation to treat trochanteric fractures.     

Magnetic resonance imaging for verifying hip fracture diagnosis why,when and how?

IntroductionHip fractures are commonly diagnosed by plain radiography. When a patient presents with negative radiographs and high clinical suspicion of fracture, guidelines recommend proceeding with magnetic resonance imaging (MRI) to diagnose the patient. The aim of this study was to assess the use of MRI in diagnosing hip fractures following trauma to the hip and describe clinical outcome after MRI-diagnosed hip fractures. The perspective was to develop new recommendations for MRI use.Materials and methods616 patients at a university hospital fulfilled the inclusion criteria of having an MRI scan of the hip following trauma between the years of 2005 and 2014. Data was collected from the patients’ medical records.ResultsThe annual number of MRIs increased over the ten-year period. Out of 616 MRI scans 228 (37%) showed fracture of the hip with a dominance of trochanteric fractures, 185 (30%) revealed pelvic fracture and 183 (29%) were negative. No patient with acute pelvic fracture had associated fracture of the hip. The main reason to proceed with MRI was a strong clinical suspicion of fracture in patients with negative initial radiographs. Amongst the 228 patients with fracture, 187 (82%) were treated operatively. Of patients with hip fracture, 90 (39%) patients suffered a general complication and 11 (5%) had hip complications. The complication rate of patients with fracture on MRI was compared to that of a cohort of general hip fracture patients at our hospital. No significant difference in twelve months’ survival or general complications could be found, but the MRI group had a significantly lower hip complication rate.ConclusionThe diagnosis set by MRI, with high share of pelvic fractures or no fracture, reflects the difficulty in differential diagnosing this group of patients. The rate of occult hip fractures was low and patients with pelvic fractures already known from X-ray did not have additional hip fractures. We found an increase in the annual number of MRIs during the 10–year-period. MRI-diagnosed hip fracture patients do not suffer more complications than the regular hip fracture patient.     

Metabolic syndrome and hip fracture: Epidemiology and perioperative outcomes

IntroductionHip fractures and metabolic syndrome (MetS) are becoming major global healthcare burdens as populations age. This study sought to determine the impact of MetS in hip fracture patients on perioperative outcomes following operative fixation or arthroplasty.MethodsData from the 2004–2014 Nationwide Inpatient Sample was used to select 3,348,207 discharges with hip fracture. MetS patients were identified by having at least 3 of 4 component comorbidities: hypertension, dyslipidemia, obesity, and diabetes. Logistic regression was used to estimate odds ratios for the association between MetS and perioperative outcomes adjusted for age, gender, race, payer status, and comorbidities.ResultsOverall, 32% of hip fracture patients were treated with open reduction internal fixation (ORIF), 28% hemiarthroplasty (HA), 18% closed reduction with internal fixation (CRPP), and 3% primary total hip arthroplasty (THA). The remaining 19% of cases were either treated via unspecified procedure of hip repair (9%), managed non-operatively (2%), underwent multiple procedures during the hospital stay (6%), or the surgical procedure data was missing (2%) and were excluded from procedural analyses. The prevalence of MetS was 7.9% and increased among minorities, patients treated at urban hospitals, with comorbidities (heart failure, kidney disease, peripheral vascular disease), and with Medicare coverage. MetS was associated with increased odds of any adverse event (p < 0.0001), specifically: acute renal failure, myocardial infarction, acute posthemorrhagic anemia. MetS was also associated with increased LOS (p < 0.0001) and increased total charges (p < 0.0001). However, MetS was associated with reduced odds of postoperative pneumonia, deep vein thrombosis and pulmonary embolism, surgical site infection, septicemia, and in-hospital mortality (p < 0.0001). The above associations were maintained for MetS patients stratified according to their treatment groups: HA, CRPP, and ORIF.ConclusionsMetS is associated with increased odds of complications in hip fracture patients but decreased odds of in-hospital mortality. This may be related to patients’ nutritional status and catabolic states in the perioperative period.     

A healthy decline in age- and sex- specific incidence of hip fractures in the elderly in the Republic of Ireland

AimThe number of patients sustaining hip fractures in the Republic of Ireland was expected to increase by 100% from 2004 to 2026. This has not been seen either in local or international literature. Our aim is to assess the age- and sex-specific incidence of hip fractures in patients over the age of 65 years and to determine whether the projected increase in incidence is mirrored in the reality of the Irish experience.MethodsThis is a retrospective observational cohort study including all patients with a hip fracture from a tertiary referral centre from 2005 to 2015. Population data was obtained from the Central Statistics Office of Ireland.Results3818 hip fractures in the over 65 age group were recorded. The highest incidence of hip fractures occurred in the 85–90 year old age group. For all ages over 65, the incidence of hip fractures in females over the 10 year period is significantly reducing (p < 0.01). There were 955 hip fractures per 100,000 in females in 2010 and 410 per 100,000 in males. In 2014, this had reduced to 668 in females and 332 in males respectively.ConclusionThe annual hip fracture incidence has decreased across both sexes in this study period. This may be associated with preventative measures and introduction of fracture liaison services. This study highlights the importance of investment in preventative strategies for a continued reduction in hip fracture incidence and will help to plan future services.     

Pathologic Versus Native Hip Fractures: Comparing 30-day Mortality and Short-term Complication Profiles

BackgroundA large body of research on native hip fractures has resulted in several evidence-based guidelines aimed at improving postsurgical care for these patients. In contrast, there is a paucity of data on pathologic hip fractures, and whether native hip fracture protocols are generalizable to this population is unknown. The purpose of this study was to compare mortality rates and complication profiles between patients with pathologic and native hip fractures.MethodsUsing the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, we identified patients who underwent surgical treatment for pathologic and native hip fractures from 2007 to 2017 and 2601 matched pairs were identified using propensity scoring. Baseline covariates were controlled for, and rates of 30-day postoperative complications and mortality were compared using McNemar’s test.ResultsPathologic hip fracture patients experienced significantly higher rates of death (6.3% vs 4.3%, P < .001), serious adverse events (17.3% vs 13.5%, P < .001), minor complications (34.3% vs 29.1%, P < .001), extended postoperative lengths of stay (30.2% vs 25.9%, P < .001), readmissions (11.9% vs 8.4%, P < .001), thromboembolic complications (3.0% vs 1.6%, P < .001), and perioperative transfusions (31.5% vs 26.4%, P < .001) compared to native hip fracture patients.ConclusionPathologic hip fractures result in significantly higher complication rates than native hip fractures after surgical treatment, suggesting that guidelines for native hip fractures may not be generalizable for pathologic hip fractures. Orthopedic surgeons should closely monitor these patients for deep vein thrombosis, utilize blood sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogenous profile of postsurgical complications.     

The best practice tariff and hip fractures: How can Northern Ireland keep up?

IntroductionCurrent hip fractures guidelines recommend surgery within 36 h of admission. The 2011 National Hip Fracture Database (NHFD) report shows our institute has the fewest patients meeting this target (9%). Northern Irelands' exclusion from the “Best Practice Tariff” means no incentive-led treatment or prioritisation of hip fracture patients.MethodWe performed a systematic review of post-operative results to highlight deficiencies in delivery of patient care. We reviewed 702 patients admitted between September 2009 and April 2012. Patients were prospectively identified and added to our Fracture Outcome and Research Database (FORD). Results were compared to national average values from the NHFD.Results16.7% of patients met the 36-h target to theatre compared to the UK average of 66%. 81.7% underwent a pre-operative orthogeriatric review. The main reasons for surgical delay were inadequate theatre space (58%) and medically unfit patients (29%). After exclusion of medically unfit patients, medically fit patients were divided into delayed surgery and not delayed categories. Medically fit patients who had delayed surgery had inferior outcomes- longer hospital stay and higher mortality as an inpatient and at 30 days.ConclusionWithout a change in funding, Northern Ireland will struggle to compete with the UK mainland and decrease mortality in this patient group.     

Hip Fracture Management during the COVID-19 Pandemic in South Korea

BackgroundThe purpose of this study was to introduce a screening system for coronavirus disease 2019 (COVID-19), to evaluate the overall orthopedic management in hip fracture patients during the COVID-19 pandemic in South Korea, and to compare the surgical results in hip fracture patients during the COVID-19 pandemic with those of the previous year.MethodsHip fracture patients who visited emergency rooms were screened at the screening clinics before admission. The medical management was carried out with the medical staff wearing surgical masks, meticulous hand hygiene observed, and a minimum distance of 2 m between patients maintained. The demographics, operative parameters, and surgical results of patients treated during the pandemic were compared with those from the previous year.ResultsFrom January 2020 to July 21, 2020, 119 patients with hip fractures (33 men and 86 women) were admitted to our institution for surgical treatment. Five patients showed symptoms of pneumonia, but no patient was positive for COVID-19. The mortality rate during the study period was 4.2%, and none of the patients died due to COVID-19. The interval between admission and surgery and the length of hospital stay were significantly shorter (p = 0.008, p = 0.002) and the proportion of spinal anesthesia was greater in hip fracture patients during the COVID-19 pandemic compared to those from the previous year (p = 0.011).ConclusionsThe COVID-19 screening system for hip fracture patients has proven to be effective in preventing intrahospital spread of the disease. Hip fracture surgery performed during the COVID-19 pandemic has shown comparable results without any COVID-19 infection and COVID-19-related mortality.     

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BackgroundHip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.MethodsPatients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.ResultsNonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.ConclusionConversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential “second hit” that both surgeons and patients should be aware of with initial decision-making.     

Assessment of trochanteric osteotomy fragment union after acetabular fracture surgery

BackgroundTrochanteric osteotomies are performed in conjunction with standard approaches to improve surgical exposure during open reduction and internal fixation (ORIF) of acetabular fractures. The literature on total hip arthroplasty reports nonunion rates as high as 30% associated with trochanteric osteotomies; however, few data exist regarding the outcomes of trochanteric osteotomies for acetabular fracture surgery. Our hypotheses were 1) patients receiving trochanteric osteotomies during ORIF of acetabular fractures have a low rate of nonunion of the osteotomy fragment, and 2) hip abduction precautions are not necessary with digastric type osteotomies.Patients and methodsA retrospective review was conducted to identify patients with acetabular fractures between July 2002 and June 2010 (n = 734 fractures) who required trochanteric osteotomies (n = 64, 9% of fractures). Forty-seven met inclusion criteria of adequate follow-up (>56 days). No excluded patient experienced a complication. Fractures were classified using the Letournel-Judet classification system.ResultsOnly seven (20%) of 35 patients who received digastric osteotomies had hip abduction precautions applied during the postoperative period. All study patients were shown to have radiographic union at the trochanteric osteotomy site (100% union rate, n = 47). Hip abduction precautions intended to protect the osteotomy site and reduce the risk of nonunion and fixation failure were infrequently applied to patients with digastric osteotomies (20%) in this cohort. Multiple protective factors against nonunion were present in this study population compared with previous arthroplasty studies from other institutions.ConclusionsTrochanteric osteotomies are not associated with a significant nonunion rate, and digastric osteotomies might be safely managed without hip abduction precautions.     

Which patients are at risk for not receiving anti-osteoporosis treatment following hip fracture?: An ACS NSQIP analysis

BackgroundScreening and management of osteoporosis is often only considered by providers when patients present with multiple fragility fractures. The objective was to determine which patients are at risk for not receiving anti-osteoporotic medication and screening immediately following open reduction internal fixation (ORIF) for hip fracture.MethodsThe 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture Database was queried to identify patients ≥ 50 years old who underwent ORIF of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures. Patients with concurrent polytrauma, malignancy, and other fragility fractures were excluded. Patients taking osteoporotic medications immediately prior to hospitalization were excluded to prevent an overlap in the screening and/or antiresorptive medication initiation rates. Multi-variate logistic regression was used to assess for factors associated with not receiving anti-osteoporotic medication immediately postoperatively.ResultsA total of 6179 patients were identified of whom 3304 (53.5%) were treated at a facility with a documented standardized hip fracture care program. Only 28.5% (N = 1766) patients received anti-osteoporosis medication immediately following ORIF. Independent factors associated with increased odds of not initiating bone protective medication were those without a standardized hip fracture care program (odds ratio [OR] 1.80 [1.58–2.06], P < 0.001), length of stay ≤ 5 days (odds ratio [OR] 1.47 [1.28–1.69], P < 0.001), patients waiting > 1 day until operation (odds ratio [OR] 1.35 [1.13–1.60], P = 0.001), patients requiring a mobility aid preoperatively (odds ratio [OR] 1.29 [1.13–1.47], P < 0.001), and patients who could not weight bear as tolerated (WBAT) on postoperative day 1 (POD 1) (odds ratio [OR] 1.25 [1.06–1.47], P = 0.008).ConclusionPatients starting anti-osteoporotic medication immediately following a hip fracture in the United States remains low (28.5%). Standardized hip fracture care programs have the greatest impact with regards to initiating anti-osteoporotic medication following hip fracture.     

Graduated compression stockings in hip fractures

INTRODUCTION

Hip fractures are the most common cause of acute admissions to orthopaedics and in the UK approximately 70,000–75,000 hip fractures occur annually. Hip fractures carry a significant risk of developing a venous thromboembolism. The National Institute for Health and Clinical Excellence (NICE) estimated that the risk of developing a venous thromboembolism in patients with hip fractures who do not receive thromboprophylaxis is 43%. In their recent guidelines, NICE recommended that combined mechanical and pharmacological thromboprophylaxis should be offered to patients undergoing hip fracture surgery and mechanical prophylaxis should be commenced at admission. The aim of this review was to search for available evidence that could support using graduated compression stockings combined with low molecular weight heparin (LMWH) in hip fracture patients.

METHODS

NICE guidelines and the reference list of the guidance were reviewed and a thorough literature search was performed on main electronic databases (MEDLINE®, Embase™ and the Cochrane Library).

RESULTS

A literature search was unable to find sufficient evidence to support the use of graduated compression stockings combined with LMWH in hip fracture settings. The guidelines are critically reviewed and the available evidence discussed.

CONCLUSIONS

The evidence supporting these recommendations is very limited and there is considerable concern regarding the safety and efficacy of the mechanical devices used in thromboprophylaxis. Further studies are needed urgently before specific guidelines can be agreed confidently for patients with hip fractures.     

The decline of hip fracture incidence rates over a 10-year period: A single centre experience

AimsAccurate epidemiological hip fracture data is essential for healthcare planning and targeted prevention strategies. Limited reports of hip fracture incidence rates in the Republic of Ireland (ROI) exist. The aim is to calculate the current age- and gender-specific incidence of hip fractures in a level 1 Trauma Centre in the ROI, and the difference in these rates over a 10 year period.Materials and methodsThis was a retrospective, population-based, observational study. The local Hospital In-Patient Enquiry (HIPE) database was used to generate data for analysis; capturing all patients admitted for hip fracture in three time periods over 10 years. Patients < 55 years old, pathological fractures, and periprosthetic fractures were excluded. Age- and gender-specific incidence rate was calculated using HIPE and national census data.ResultsAbsolute number of hip fractures rose by 8.5% between 2008/09 (n = 800) and 2018/19 (n = 868) time periods. Cervical hip fractures dominated in all 3 time periods. The average age of patients remained at 80 years but length of stay for patients was reduced by 16% 5 years later and by 21% 10 years later from the initial study point. Both the entire and susceptible (> 55 years) population numbers increased by 13% and 30%, respectively, yet overall hip fracture incidence rate declined 10 years on. Hip fracture incidence rate in the entire population fell by 3.23 per 100,000 population, and by 65.11 per 100,000 population in the susceptible population. The majority of both male and female age groups exhibited declining annual incidence rates over the 10 year study period.ConclusionResults are consistent with the global experience of declining overall incidence rate of hip fractures, despite rising susceptible population numbers. This report adds to the sparse hip fracture incidence data available in the ROI which can be applied in future healthcare planning strategies.     

National audits of hip fractures: Are yearly audits required?

IntroductionHip fractures are a significant cause of morbidity and mortality to the increasing elderly population. The Scottish Hip Fracture Audit started in 1993 with national audits from 2002. It was a national prospective audit reporting on clinical standards in hip fracture care and produced an annual report. Due to national funding changes the continual audit was discontinued in 2008. In 2013, the MSK Audit Group published a “snapshot” into a 4 month period of hip fracture care in Scotland. Our purpose was to identify whether there had been an initial improvement in hip fracture care and whether this improvement was sustained with the discontinuation of the annual audit.MethodsThe reported outcomes from the annual Scottish Hip Fracture Audit from 2003 to 2008 were compared to the latest MSK Hip Fracture Audit published in 2013. Some data is available from the 2014 MSK Hip Fracture Audit and this was also used for comparison purposes. Local audit co-ordinators at each participating site collected a data-set for all patients admitted with a hip fracture. The case mix variables and management variables were compared for the reported years.ResultsThe continual audit demonstrated an improvement in the percentage of patients discharged from accident and emergency in 4 h (80.5% 2003 vs. 96% 2008) which was not maintained 5 years later. An improvement in the percentage of patients having surgery within 48 h of admission (89.9–98.4%) was also not maintained after 5 years (91.8%). 30 day mortality improved with continual audit, a trend which continued in 2013. The re-introduction of continuous audit in 2014 demonstrated an improvement in accident and emergency waiting times and time to theatre.DiscussionThe Scottish Hip Fracture Audit demonstrated improved standards of care until it was discontinued in 2008. The improvement was not sustained throughout all variables with the 2013 audit. With the re-introduction of regular audit, standards once again improved. We would recommend a more regular audit in an effort to not only improve standards of care for patients with a hip fracture but to maintain them.     

The outcome of intracapsular hip fracture fixation using the Targon Femoral Neck (TFN) locking plate system or cannulated cancellous screws: A comparative study involving 2004 patients

AimThis study compares the outcome of intracapsular hip fracture fixation using the Targon Femoral Neck (TFN) locking plate system with the standard fixation using cannulated cancellous screws (CCS).Patients and methodAnalyses of a prospectively collected data of all patients treated for intracapsular hip fractures using the TFN system and CCS at our department over a period of 28 years. Baseline characteristics and specific outcome measures where compared. The primary outcome measure was fracture revision during the 1st year. Secondary outcome measures were fracture complications, any revision surgery, mortality and mobility status at one year after surgery.ResultsA total of 2004 fractures were included, a third (n = 725, 36.2%) were treated using the TFN system. There were higher rates of non-union (19.5% vs 9.5%) and revision surgery (19% vs 9%) during the first year in the CCS cohort. Revision surgery was also higher in the same group during the whole of the follow-up period (22.2% vs 14.9%). The first year’s mortality rate was higher in the CCS cohort (21.1% vs 17.5%) but the reduction in mobility and mobility scores was the same in both cohorts.ConclusionThis study includes the largest cohort of cases treated for intracapsular hip fractures using the TFN system. It demonstrated that the TFN system was associated with lower rates of non-union, revisions and re-operations for any cause.     

Hip Fracture Surgery without Transfusion in Patients with Hemoglobin Less Than 10 g/dL

BackgroudHip fracture surgery is associated with blood loss, which may lead to adverse patient outcomes. The hemoglobin level declines gradually in most hip fracture cases involving femoral neck fractures and intertrochanteric fractures. It decreases further after hip fracture surgery due to perioperative bleeding. We developed a protocol, which avoids transfusion in hip fracture surgery, and reviewed the hemodynamic outcomes of patients with hemoglobin less than 10 g/dL without transfusion.MethodsFrom 2014 to 2019, we retrospectively recruited 34 patients with hip fractures and a hemoglobin level less than 10 g/dL, who refused to undergo transfusion. There were 19 patients with femoral neck fractures and 15 patients with intertrochanteric fractures. Our patient blood management (PBM) protocol involving 4,000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) was applied to all included patients. Intraoperatively, a cell saver and tranexamic acid were used. Postoperatively, the protocol was maintained until the patients'' hemoglobin level reached 10 g/dL. We evaluated the feasibility of our protocol, perioperative complications, and hemodynamic changes.ResultsNineteen patients with femoral neck fractures underwent bipolar hemiarthroplasty and 15 patients with intertrochanteric fractures underwent internal fixation with a cephalomedullary nail. The mean hemoglobin level was 8.9 g/dL (range, 7.3–9.9 g/dL) preoperatively, 7.9 g/dL (range, 6.5–9.3 g/dL) immediately postoperatively, 7.7 g/dL (range, 4.3–9.5 g/dL) on postoperative day 1, 7.4 g/dL (range, 4.2–9.4 g/dL) on postoperative day 3, 8.1 g/dL (range, 4.4–9.7 g/dL) on postoperative day 5, 8.5 g/dL (range, 4.5–9.9 g/dL) on postoperative day 7, and 9.9 g/dL (range, 5.7–11.1 g/dL) on postoperative day 14. The average intraoperative bleeding was 206.2 ± 78.7 mL. There was no case associated with complications of anemia.ConclusionsHip fracture surgery in patients with hemoglobin less than 10 g/dL was feasible without the need for transfusion using our PBM protocol in 34 patients. Using this protocol, the operation was conducted safely despite the anemic condition of patients with fractures whose hemoglobin was less than 10 g/dL.     

Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Exploratory Health-Related Quality of Life and Patient-Reported Functional Outcomes of a Multi-Centre 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients

PurposeFemoral neck fractures in young patients are typically managed with internal fixation using either cancellous screws or a sliding hip screw (SHS). Although fixation preserves the hip joint, patients are still at risk of complications and poor clinical outcomes which lead to diminished function and health related quality of life (HRQL). The Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2) pilot randomized controlled factorial trial evaluated the effect of surgical fixation (cancellous screws vs. SHS) and vitamin D supplementation vs. placebo on patient-reported function and HRQL.MethodsPatients between the ages of 18-60 years with a femoral neck fracture requiring surgical fixation were eligible. Eligible patients were randomized to receive either a sliding hip screw or cancellous screws for fracture fixation AND vitamin D₃ 4,000 IU or placebo daily for 6 months. Patient-reported function (Hip Outcome Score) and HRQL (Short Form-12) were assessed at standardized time points in the 12 months following their fixation surgery. Patient-reported function and HRQL were summarized using means, SD, and 95% confidence intervals (CIs), or percentages and counts. Longitudinal data analysis with mixed models was used to explore the effect of treatment group and time on the patient-reported function and HRQL.Results86 of the 91 patients randomized into the FAITH-2 pilot study were deemed eligible. There were no significant differences in patient-reported function or HRQL between the treatment groups at 12 months post-fracture. At the 6- and 9-month assessments, a potential benefit in hip function was seen in the cancellous screw group. In all treatment groups, participants reported lower function and HRQL at 12 months post-fracture as compared to their pre-injury assessment.ConclusionsFew differences were found in function and HRQL among the treatment groups in the FAITH-2 pilot study. Despite modern implants and vitamin D supplementation, neither function nor HRQL returns to baseline in this population. Additional efforts to improve the outcomes of these challenging injuries are still needed.Level of EvidenceTherapeutic Level II     

Technical note and surgical outcomes of percutaneous cable fixation in subtrochanteric fracture: A review of 51 consecutive cases over 4 years in two institutions

Background

The main purpose of this study is to introduce our surgical technique and report surgical outcomes for percutaneous cable fixation in the treatment of subtrochanteric femoral fractures.