Aims. The aim of this study was to describe variation in hip fracture treatment in Norway expressed as adherence to international and national evidence-based treatment guidelines, to study factors influencing deviation from guidelines, and to analyze consequences of non-adherence. Methods. International and national guidelines were identified and treatment recommendations extracted. All 43 hospitals routinely treating hip fractures in Norway were characterized. From the Norwegian Hip Fracture Register (NHFR), hip fracture patients aged > 65 years and operated in the period January 2014 to December 2018 for fractures with conclusive treatment guidelines were included (n = 29,613: femoral neck fractures (n = 21,325), stable trochanteric fractures (n = 5,546), inter- and subtrochanteric fractures (n = 2,742)). Adherence to treatment recommendations and a composite indicator of best practice were analyzed. Patient survival and reoperations were evaluated for each recommendation. Results. Median age of the patients was 84 (IQR 77 to 89) years and 69% (20,427/29,613) were women. Overall, 79% (23,390/29,613) were treated within 48 hours, and 80% (23,635/29,613) by a surgeon with more than three years’ experience. Adherence to guidelines varied substantially but was markedly better in 2018 than in 2014. Having a dedicated hip fracture unit (OR 1.06, 95%CI 1.01 to 1.11) and a hospital hip fracture programme (OR 1.16, 95% CI 1.06 to 1.27) increased the probability of treatment according to best practice. Surgery after 48 hours increased one-year mortality significantly (OR 1.13, 95% CI 1.05 to 1.22; p = 0.001). Alternative treatment to arthroplasty for displaced femoral neck fractures (FNFs) increased mortality after 30 days (OR 1.29, 95% CI 1.03 to 1.62)) and one year (OR 1.45, 95% CI 1.22 to 1.72), and also increased the number of reoperations (OR 4.61, 95% CI 3.73 to 5.71). An uncemented stem increased the risk of reoperation significantly (OR 1.23, 95% CI 1.02 to 1.48; p = 0.030). Conclusion. Our study demonstrates a substantial variation between hospitals in adherence to evidence-based guidelines for treatment of hip fractures in Norway. Non-adherence can be ascribed to in-hospital factors. Poor adherence has significant negative consequences for patients in the form of increased mortality rates at 30 and 365 days post-treatment and in reoperation rates. Cite this article: Bone Joint Open 2020;1-10:644–653

The Thompson hemiarthroplasty is a common treatment option for acute neck of femur fractures in the elderly population. Our department noted a significant number of patients returning with thigh pain, radiographic loosening and femoral osteolysis following cemented implantation of the titanium alloy version of the Thompson hemiarthroplasty. We are not aware of any previous reports documenting complications specific to the titanium Thompson implant and a retrospective cohort study was therefore initiated following clinical governance approval. 366 titanium alloy Thompson prostheses were implanted for hip fracture treatment between 2017 and 2020. As of February 2023, 6 of these have been revised at our hospital. 5 were revised for symptomatic femoral osteolysis and 1 presented with an acute periprosthetic fracture. All revised cases were determined to be aseptic. 32 living patients were excluded from recall on compassionate grounds due to permanent nursing home residence. 47 living patients were identified of which 33 attended for xray. 28 deceased and/or nursing home resident patients who had pelvis x-rays in the previous 12 months were also included in the analysis. Including the 6 index hips already revised, a total of 61 hip xrays were analysed, of which 19 hips (31.1%) showed radiographic evidence of femoral osteolysis or loosening. We conclude that there is a concerning incidence of femoral osteolysis and implant loosening associated with the titanium Thompson implant. We have discontinued use of the implant and reported our experience to the MHRA. We encourage other Scottish Health-Boards who use this implant to consider enhanced follow-up

Aims. This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results. Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion. There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720

Elderly patients undergoing surgery for a hip fracture are at risk of thromboembolic events (TEV). The risk of TEV is now rare due to thromboprophylaxis. However, hip fracture treatment has evolved over the last decade. The risk of TEV may have been modified. The objective of this study was to determine the risk of symptomatic TEV following surgery for a hip fracture, in an elderly population. Retrospective cohort study of all patients > 65 years old undergoing surgery for a femoral neck or intertrochanteric hip fracture in two academic centers, between January 1st 2008 and January 1st 2019. The follow-up was fixed at 3 months. The cumulated risk of thromboembolic events was calculated using the Kaplan-Meier estimator and a predictive logistic regression model was used to determine risk factors. 3265 patients were eligible for analysis. The mean age was 83.3 ±8.1 years old and 75.6% of patients were female. The mortality was 7.55% (N=112) at 3 months. 98.53% of this cohort received thromboprophylaxis. The cumulated risk for a thromboembolic event was 3.55% at 1 month and 6.41% at 3 months (N=99). There were 9 fatal pulmonary embolisms. 89.19% thromboembolic events occurred within 20 days following surgery. Chronic obstructive pulmonary disease (odds ratio 1.909 [1.179–3.089]), renal failure (odds ratio 1.896 [1.172–3.066]) and the use of a bridge between different types of anticoagulant (odds ratio 2.793 [1.057–7.384]) were associated with TEV. The risk of bleeding was 5.67% at 1 month and 9.38% at 3 months (N=142). 77% of bleeding events were hematomas. The risk of thromboembolic events is higher than expected in a population treated for this condition. Most thromboembolic events occur shortly following surgery. The risk of bleeding is high and most of them are hematomas. Future research could focus on the management of thromboprophylaxis in elderly patients undergoing surgery for a hip fracture

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Aims

To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

Aims

The primary aim of this study is to compare mobility status of patients receiving oral oxycodone with those receiving subcutaneous alfentanil as analgesic methods prior to mobilization to help physiotherapy compliance after hip fracture surgery. The secondary aims are to assess postoperative pain, health-related quality of life, in-hospital length of stay, total use of analgesia over postoperative days 1 and 2 (POD 1 and POD 2), complication rates within 30 days, and 30-day mortality rates.

Aims

This study aimed to identify risk factors (patient, healthcare system, and socioeconomic) for mortality after hip fractures and estimate their relative importance. Further, we aimed to elucidate mortality and survival patterns following fractures and the duration of excess mortality.

Introduction: The treatment of hip fracture patients differs widely throughout Europe. In the SAHFE project (Standardised Audit of Hip Fractures in Europe) it was found that both waiting time to operation and mean hospitalisation time for operated patients was considerably higher in certain Mediterranean countries compared to the Northern parts of Europe. Local tradition influences both the choice of operation method and the routines for rehabilitation. Background factors were rather similar with mean age around 80 years and a predominance of female patients, 75% were women. Experiences from good examples of treatment throughout Europe are important to optimise the overall hip fracture treatment of benefits both for the individual patient and for the society in form of resources needed. The costs for hip fracture treatment are already considerable and with an ageing population the resources for treatment of these patients need to be optimised throughout the world. With more elderly in the populations, the total number of hip fracture patients is prognosticated to increase 5 times in the next 50 years. This symposium deals with means to improve the treatment results by focusing on the patient to make possible the best rehabilitation results after different operative procedures. Examples will be given from centres who have worked on the whole treatment chain for these elderly resource consuming patients

Hip fracture treatment strategies continue to evolve with the goal of restoring hip fracture victims to Pre-injury Functional levels. Strategies for improved treatment have focused on fracture exposure, reduction, provisional fixation and definitive fixation with implant designs optimised for fracture union with minimal implant failure as originally proposed by Lambotte. Multiple implant designs have been conceived based on perceived inadequacies of previous generational designs. To better understand this evolutionary process, it is necessary to review the predecessors of modern fracture treatment and understand their design concepts and results. It is interesting that the modern era of surgical treatment of hip fractures actually began in 1902, when Dr Royal Whitman advocated the necessity of a closed reduction of adult hip fractures under general anesthesia and stabilisation by hip spica cast. Dr Whitman predicted the evolution of stabilisation by internal fixation and commented on this in his 1932 JBJS editorial emphasising the importance of surgical treatment of fractures. Dr Smith-Peterson, also from New York, in 1925 developed the 1st commercially successful hip implant, a tri–flanged nail. These first surgeries were performed with an open reduction, through a Smith-Petersen approach without radiographic control. This nail device was rapidly modified in the 1930's to permit insertion over a guide wire with a radiographic controlled insertion technique, a minimally invasive procedure. Nail penetration and implant failure in pertrochanteric fractures led to the rapid development of side-plates and a refocus on reduction stability. This led to a period of primary corrective osteotomies for enhanced stability, but fell out of failure after the sliding hip screw concept took hold. Originally conceived by Godoy-Moreira and Pohl independently in the 1940s, it became rapidly accepted as a method to avoid nail penetration and implant failure, unfortunately at the expense of accepting malunion and collapse of the fracture. Even the importance of rotational stability was discarded as insignificant by Holt in 1963. The concept of reduction of the Antero-Medial cortex was forgotten in favour of the Tip-apex distance as the only important variable in reduction to avoid implant cut-out. The concept of malunion of pertrochanteric fractures was simply deleted from consideration with disregard for the possible association of impaired functional recovery. Several recent papers that improved functional recovery is possible when these new implants are coupled with successful reduction strategies. Further studies are needed to identify the correct choice of implant for the appropriate fracture configuration, which may lead to a revision of our current fracture classification systems and our concepts of stability

Aims

A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery.

Introduction. We implemented an exhaustive operative and supervision algorithm for surgical treatment of hip fractures primarily based on own previously published literature. The purpose was to improve supervision and reduce the rate of reoperations. Materials and methods. 2000 consecutive unselected patients above 50 years admitted with a hip fracture were included, 1000 of these prospectively after implementation of the algorithm. Demographic parameters, hospital treatment and reoperations within the first postoperative year were assessed from patient records. The algorithm dictated the surgical treatment based on three objective patient parameters: age, new mobility score and fracture classification on pre-operative anterior-posterior and axial radiographs. Intra capsular fractures were treated with two parallel implants, a sliding hip screw, an arthroplasty or resection of the femoral head. Extra capsular fractures were treated with a sliding hip screw or an intramedullary nail. Supervision of junior registrars was mandatory for the prosthesis and intramedullary nail procedures. Results. 931/1000 operative procedures were operated according to the algorithm, compared to only 726/1000 prior to its introduction (p<0.001). Retrospectively we found that 13% (208/1657) of operative procedures performed as the algorithm dictated were reoperated compared to 28% (96/343) of operative procedures performed with other methods (p<0.001). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score and level of surgeon's experience, not following the algorithm was a predictor for re-operation (p<0.001 log. reg.). After implementing the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192/1000 to 105/1000 (p=0.039). The rate of reoperations declined from 18% to 12% (p<0.001, log. reg.), with a 24% (112/467) to 18% (87/482) decline for intra capsular fractures (p=0.025) and a 13% (68/533) to 7% (37/518) decline for extra capsular fractures (p=0.002). The extra bed-days caused by reoperations were hereby reduced from 24% to 18% of total hospitalization. Conclusion. An exhaustive algorithm for hip fracture treatment can be implemented. In our case, the algorithm both raised the rate of supervision and reduced the rate of reoperations, the latter saving many hospital bed-days

Introduction: We derived an exhaustive operative and supervision guideline for the treatment of hip fractures from the current international and own published literature, and implemented the guidelines in our department. Methods: 1274 unselected consecutive patients admitted with a hip fracture were included, 336 of these prospectively after implementation of the new guideline. Demographic parameters, hospital treatment and re-operations were assessed from patient journals. Re-operations were recorded after six months. Results: 95% (320/336) of operative procedures were found to have followed the new guideline treatment compared to 78% (733/938) prior to its introduction (p< 0.001 X2). Retrospectively we found that only 12% (121/1053) of operative procedures performed as the new guideline prescribes were re-operated compared to 24% (53/221) of operative procedures performed with other methods (p< 0.001 X2). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score, time from admission to operation and level of surgeon’s experience, not following the guideline was the only significant predictor for re-operation (p< 0.001 log. reg.). After implementing the guideline, the rate of unsupervised junior registrars performing operations declined from 20% (188/938) to 6% (21/336, p< 0.001 X2). The rate of reoperations declined from 15% (139/938) to 10% (35/336, p=0.044 X2, p=0.043 log.reg.), with a 20% (85/436) to 13% (23/174) decline for intracapsulary and an 11% (54/502) to 7% (12/162) decline for extracapsulary fractures. Conclusion: An exhaustive operative guideline for hip fracture treatment can be implemented. In our case, the guideline both raised the rate of supervision and reduced the rate of reoperations

Background: Hip fracture trials have employed a wide range of patient-reported outcomes (PRO) suggesting a lack of consensus among clinicians on what are considered the most relevant outcomes. Variability in functional outcome reporting in hip fracture management creates challenges in the comparison of results across trials. The purpose of this study was to conduct a systematic review of the functional outcomes fielded in randomized controlled trials in post-operative hip fracture treatment for the aged. We hypothesized that over time there had been an increase in patient-reported outcomes along with aggregate scoring systems of hip function. Methods: An electronic database search was conducted using key terms combining: ‘hip fracture’ with ‘RCT’ with ‘age 65 years and over’. s and titles were screened in duplicate and independently. All of the articles that met eligibility criteria were reviewed using the 21-point Detsky Quality Assessment Scale. Results: In 2451 citations, 86 studies were included and also met accepted standards of inter-observer reliability (kappa, 0.92; 95% confidence interval, 0.87 to 0.98). The mean score (and standard error) for the quality of the randomized trials was: 75.8% ± 1.76% (95% confidence interval, 72.3%–79.3%) and 27 (32.6%) of the trials scored < 75%. Medical trials had a higher mean quality score than did surgical trials (83.7% compared with 72.7 %, p = 0.025). 59 trials (30 Surgical, 11 medical and 18 rehabilitation trials) scored > 75% in quality. Out of 86 trials, 8 (13.6%) used EQ-5D for utility and 6 (10.1%) used the SF-36 health status measures. At most, 12 trials used the same composite score: 12 (13.9%) ADL Katz Index, 9 (10.4%) trials used the HHS and 8 (9.3%) trials used Parker’s mobility score. Conclusion: Although in the past decade more studies have made use of outcome instruments that capture both impairment and functional status in one aggregate score, there is a lack of standardized assessment

Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

Hip fractures have increased in most western countries during the end of the last century. This increase will continue mainly because of an increasing number of elderly persons and also due to an increase in the risk of hip fractures in the oldest. This constitutes a threat to resources for medical care. Practise differs concerning choice of operation method and principles for rehabilitation throughout the world. A national registration of the outcome after hip fractures in the elderly started in 1988 in Sweden to compare different methods of surgery, mobilization and rehabilitation. This project has attracted great international interest and several centres have participated with prospective registration. With support from the European Commission a project was started in 1995 called Standardised Audit of Hip Fracture in Europe (SAHFE). The project aims to encourage centres in Europe to participate in a hip fracture audit with a defined data set consisting of a core of 34 questions which includes outcome measures at 4 months from operation. Printed forms are distributed to the participants as well as a computer program designed for the project. In addition there is a large number of optional questions. Each participating centres collects its own data and registers for own analysis. The data are then sent to the project centre in Lund. Hospitals wishing to participate in these international comparisons are welcome. The SAHFE project will promote comparisons of demographic features, surgical technique and rehabilitation methods to facilitate the dissemination of the best practise of hip fracture surgery and rehabilitation throughout Europe. Further international participation will widen the spectrum and facilitate improvements of the hip fracture treatment of benefit both to the patients and the society which has to provide health care to the increasing number of elderly

Introduction: Older age is a risk factor for a poorer survival prognosis after hip fracture. Some other variables, such as male sex, dependency and dementia also contribute to a worse result expectations. However, since the association between surgery complications and other variables, such as age has been poorly researched, in this paper we study, within a major project on hip fractures, the association between age and nosocomial infections after hip fracture surgical treatment. Material and Methods: We have designed a cohort study and have followed them after surgery with the aim of studying NI rates. We reviewed the records of all patients operated on for hip fracture in our Institution between 2006, and 2008. Data on all hip fractures were prospectively collected as from patient admission. The data collection was based on the “Minimum Data Base Group” at our National Health System. Together with affiliation, full clinical history, and also complications are all included in our Hospital data base. We considered a nosocomial infection (NI) as any infection developed within three months after a main surgical procedure was addressed for a hip fracture (infection either at the surgical site, pneumonia, urological infection, or others). Patients were classified, in terms of co-morbibidity, according to worldwide accepted Charlson et al criteria. A univariate and multivariate analysis were performed, by using simple and multiple logistic regression model. Results: We collected 912 patients operated on for a hip fracture. Age was associated to infection, either in considering it alone (crude OR 0,96, CI of 95% = 0,95; 0,97; p=0,0004) or in considering it together with the other variables (multivariate analysis: adjusted OR 1,04; CI of 95% = 1,01; 1,07; p=0,007). None of the other variables were associated to nosocomial infection. Mental disease (crude OR 0,79, CI of 95% = 0,41; 1,53; p=0,49; adjusted OR 0,74, CI of 95% = 0,37;1,46; p=0,38), gender (OR=0,93 [CI of 95% 0,51; 1,68] p=0,78; adjusted OR=1,14 [0,62; 2,10] p=0,67), or co-morbidities (crude OR for index 1: 1,07 [CI of 95% 0,60; 1,90]; OR=1,07 [CI of 95% 0,43; 2,65] p=0,97) adjusted OR for index 1: 0,99 [CI of 95% 0,54; 1,80] p=0,97], for index 2, which includes 2–7, OR=1,02 [CI of 95% 0,40; 2,62] p=0,96). Discussion: Since age, in this research, has shown to have a definite correlation with nosocomial infections, whenever older patients are operated on for hip fracture treatment, prophylactic protocols for infection prevention should be individualized, according to patient age. The likelihood of adding communitarian infections when studying non surgical site infections, incubated before or after hospital stay is unknown. However, since the earliest infection developed at the second hospitalization day, we believe that the aim of this research is not affected for that

Background: Hip fractures are a common cause of hospitalisation amongst elderly patients, imposing a burden on resources and resulting in significant morbidity and mortality. Despite the high incidence questions remain surrounding the efficacy of current treatment protocols. There has also been relative neglect, within current literature, of the ‘young’ hip fracture patient. Objectives: To analyse clinical and patient-reported outcomes for patients with hip fractures treated at two Australian level-1 trauma centres, and, to highlight key differences between the ‘typical’ patient (age> 60 years) and those aged 60 years or less. Methods: Patients with traumatic proximal femoral fractures treated at The Royal Melbourne and Alfred hospitals between 2003 and 2006 were identified via the Victorian Orthopaedic Trauma Outcomes Registry. Patient-reported outcomes were prospectively measured at 6 and 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12) and a Numerical Pain Scale. A priori defined clinical outcomes were also determined by reviewing medical records and X-rays. Results: A total of 695 patients were identified with similar distribution between institutions. The male: female ratio was 1:2 and 13.8% were aged 60 years or less at presentation. ‘Community-dwellers’ accounted for 69.9% with 25.6% presenting from an institutional setting. Displaced subcaptial fractures (AO-31B3) occurred most commonly. Median hospital length of stay was 12 days. Inpatient mortality reached 5.5% whilst mortality at 6 and 12 months post-injury was 17.1% and 22.6% respectively. Upon discharge 16.1% returned to the community and 60.5% required rehabilitation. At 6 months 48.0% were residing at home and 30.5% at an institutional setting. Institutionalisation decreased to 27.7% at 12 months, approaching pre-injury levels. Mean physical SF-12 scores remained well below population norms at 12 months (36.4 vs 48.9). Younger patients demonstrated significantly different results with reference to presentation, management and outcomes. Several factors were highlighted as predictors of mortality and/or functional recovery. Conclusions: Mortality following hip fracture treatment at an Australian level-1 trauma centre is comparable to statistics achieved by similar international institutions. The rise in mortality is greatest within the initial 6 months representing a period during which close medical attention is paramount. The Mortality predictors highlighted may be useful in guiding this resource allocation. Patient-reported health status also plateaus following the initial 6 months, warranting a review of current protocols to ascertain whether this represents a golden ‘window-period’ for successful rehabilitation or whether appropriate care is not being provided beyond 6 months. Patients aged 60 years or younger represent a significant and unique group. Approach to management and goals of treatment should be tailored accordingly

Introduction: Complex humerus fractures is a frequent lesion with a greater incidence than hip fractures. The treatment is a challenge for orthopaedic surgeons. We present a new osteosynthesis technique based on a mini invasive nailing with a self stabilized screws interlocking. Methods: We used a 15 cm intramedullary nail with a 7, 8, or 9 mm width. The proximal locking is carried out in the articular and tuberosity fragments with cancellous screws. Two or three small fragments long threaded screws are usually necessary to stabilize the fragments and the humeral head. Rigid fixation is obtained with an excellent stability due to the intra nail locking of the screws. Distal interlocking is carried out at the level of the deltoid tuberosity ensured by 1 or 2 frontal screws introduced away from the nerves and blood supply. Functional therapy is initiated on the first post-operative day. Results: We present a series of the first 64 cases done in a prospective approach. The patients have been classified according to the Constant score. The mean balanced score is 88% at the two years follow-up. Among the advantages of the technique we point out the great comfort of the patients with a minimal pain and the possibility of an immediate rehabilitation after the surgery. Because of the use of the nail, we stop the use of the hemiarthroplasty even in the 4 fragments fractures. Conclusion: Telegraph nailing of the complex proximal humeral fractures gives excellent results at the two years follow-up, sometimes unexpected even in the more complex cases and avoid the use of shoulder arthroplasty in the traumatic indication