Fragility fractures are an emerging healthcare problem in Sub-Saharan Africa and hip fractures (HFs) are associated with high levels of morbidity, prolonged hospital stays, increased healthcare resources utilization, and mortality. The worldwide average healthcare cost in the first-year post HF was US$43,669 per patient in a 2017 systematic review, however there are no studies quantifying fracture-associated costs within SSA. We estimated direct healthcare costs of HF management in the South African public healthcare system.

We conducted a prospective ingredients-based costing study in 200 consecutive consenting HF patients to estimate costs per patient across five regional public sector hospitals in KwaZulu-Natal (KZN). Resource use including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by relevant unit costs, estimated from KZN Department of Health hospital fees manual 2019/20, in local currency (South African Rand, ZAR). Generalised linear models were used to estimate total covariate adjusted costs and cost predictors.

The mean unadjusted cost for HF management was ZAR114,179 (95% CI; ZAR105,468–125,335). The major cost driver was orthopaedics/surgical ward costs ZAR 106.68, contributing to 85% of total cost. The covariate adjusted cost for HF management was ZAR114,696 (95% CI; ZAR111,745–117,931). After covariate adjustment, total costs were higher in patients operated under general anaesthesia compared to surgery under spinal anaesthesia and no surgery.

Direct healthcare costs following a HF are substantial: 58% of the gross domestic per capita (US$12,096 in 2020), and six-times greater than per capita spending on health (US$1,187 in 2019) in SA. As the population ages, this significant economic burden to the health system will increase. Further research is required to evaluate direct non-medical, and the indirect costs incurred post HF.

In Alberta there are over 2,700 hip fractures per year costing the health system over $24 million in acute care costs alone. 50% of hip fracture patients have had a prior fragility fracture as a result of underlying osteoporosis (OP) that has never been assessed or appropriately treated. The Fracture Liaison Service (FLS) in Alberta aims to improve appropriate osteoporosis care, highlight and address gaps within seniors care through OP management, and provide a geriatric syndrome triage service.

The FLS has developed a linkage with the Emergency Department (ED) geriatric team whereby hip fracture patients are identified in ED using a screening tool for geriatric syndromes prior to their surgery, allowing the FLS to follow through on comorbidities likely contributing to falls. An inpatient orthopaedic unit with a dedicated Registered Nurse (RN) and a Care of the Elderly Physician see and assess hip fracture patients after surgery for appropriate osteoporosis management and treatment. Screening tools have been developed to quickly detect underlying dementia and to quantify frailty to determine life expectancy and appropriate osteoporosis therapy. Patients are also referred to Geriatric Assessment Units and fall prevention programs. Patients are then contacted in the community at 3, 6,9,12 months by the FLS RN to follow up on osteoporosis therapy, and arrange other needed tests (i.e. bone mineral density, vitamin D) as needed. Information is sent to their family physician with all results. Prior to the patient's discharge from the FLS at one year, a final hand-over letter from the program will be provided outlining the plan of care for the patient.

The FLS launched in June 2015 at the Misericordia hospital in Edmonton, Alberta (with plans to expand provincially). Currently 3 out of 4 hip fracture patients per week are being identified in the ED. Ninety-eight hip fracture patients have been identified post-surgery, with 71 patients eligible for enrollment in the program (five deceased patients). Sixty-six (50%) of those enrolled were discharged on osteoporosis medication compared to 8% prior to the program initiation. Seventeen (26%) of those were new medication starts. Of those not started, 7(11%) was patient choice. 11(31%) will be reassessed at 3 months for appropriate therapy. Nineteen (27%) of patients were referred to other inpatient or outpatient programs (i.e. falls, memory). Three month follow up calls have begun with patients for further data collection and a full 1 year qualitative and quantitative evaluation will be done.

The implementation of an FLS with dedicated personnel to proactively manage and treat patients with appropriate investigations and interventions can close the care gap that exists in OP care. It also addresses gaps in senior care and provides appropriate referral to community geriatric programs, to improve quality of life and prevent future fractures.

In 2007, the National Hip Fracture Database (NHFD) was conceived in the United Kingdom (UK) as a national audit aiming to improve hip fracture care across the country. It now represents the world's largest hip fracture registry. The purpose of the NHFD is to evaluate aspects of best practice for hip fracture care, at an institutional level, that reflect the evidence-based clinical guidelines and quality standards developed by the National Institute for Health and Care Excellence. No national program currently exists, equivalent to the NHFD, in Canada despite evidence suggesting that national audit programs can significantly improve patient outcomes. The purpose of this study was to evaluate aspects of best practice for hip fractures at our Canadian academic tertiary referral center using the Key Performance Indicators (KPI) and benchmarks used by the NHFD. In doing so, we aimed to compare our performance to other hospitals contributing to the NHFD database. A retrospective cohort study was conducted on consecutive patients who presented to our Canadian center for surgical management of a hip fracture between August 2019 to September 2020. Fracture types included intertrochanteric, subtrochanteric, and femoral neck fractures treated with either surgical fixation or arthroplasty. Cases were identified from the affiliate institute's Operatively Repaired Fractures Database (ORFD). The ORFD prospectively collects patient-level data extracted from electronic medical records, operating room information systems, and from patients’ discharge summaries. All applicable data from our database were compared to the established KPI and benchmarks published by the NHFD that apply to the Canadian healthcare system. Six hundred and seven patients’ data (64.5% female) were extracted from the ORFD, mean age 80.4 ± 13.3 years. The NHFD contains data from 63,284 patients across the entire UK. The affiliate institute performed inferiorly compared to the NHFD for two KPIs: prompt surgery (surgery by the day following presentation with hip fracture, 52.8% vs. 69%) and prompt mobilization after surgery (mobilized out of bed by the day after operation, 43.0% vs. 81.0%). However, more patients at the affiliate institute were not delirious when tested postoperatively (89.6% vs. 68.4%). There was no significant difference in the average length of stay (12.23 days versus 13.5 days) or in 30-day mortality rate (8.4% versus 8.3%). More than half of all KPI's and benchmarks for patients receiving a hip fracture surgery at our tertiary referral center in Canada ranked significantly lower than patients receiving a hip fracture surgery in the UK. These findings indicate that perhaps a national audit program should be implemented in Canada to improve aspects of hip fracture care, at an institutional level. Following evidence-based clinical guidelines and using standardized benchmarks would encourage change and foster improvement across Canadian centres when necessary

One of the most important sequelae to ageing is osteoporosis and subsequently hip fractures. Hip fractures are associated with major morbidity, mortality and costs. Most patients require surgery to restore mobility. Provision of surgery and its complications is poorly understood in South Africa. Our aim was to collect and report current hip fracture care at four centres in South Africa, as well as reporting surgical and general patient outcomes. A three year retrospective cohort at four centres will be described, focussing on provision of surgical care, mortality, types of surgery and complications. We identified 562 patients who had surgical intervention for fragility fractures, 66% were females. Forty nine percent had open reduction and internal fixation, 28% had hemi-arthroplasty replacement whilst 23% had total hip replacements. Twenty percent of patients had operative intervention within 36 hours of presentation to the emergency department. Mortality was 9% at 30 days. The most common complications were lower respiratory infections (29%), urinary tract infections (21%) and surgical site infections (9%). This is the largest cohort of surgically treated hip fracture from South Africa. Proportions of patients receiving different surgical interventions such as THR are comparable to the broader literature. However a number of key performance indicators such as surgery within 36 hours are challenging to meet. Given the changing demographics of South Africa, this study provides an early insight to contemporary care and may help provide direction for broader national strategies for reporting and improving hip fracture care

Failed internal fixation of hip fracture is a problem with varied aetiology. This becomes more complex when associated with infection. Total hip arthroplasty (THA) remains the only option to restore hip biomechanics when there is partial/complete head destruction associated with it. A retrospective review was performed for 22 consecutive patients of THA following failed infected internal fixation between Sept. 2001 and Nov. 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, six failed osteotomies following proximal femoral fractures and five failed screw fixations for transcervical fractures. The average age of the patients was 48.5 years and average follow up period was 3.5 years (16 months–7.5 years). All the patients have undergone two stage revision surgeries. The average Harris Hip Score improved from 35.5 to 82.8 at the latest follow up. None of the patients had recurrence of infection. One patient developed sciatic nerve palsy, recovered partially at one year following surgery. The results were comparable to primary arthroplasty in femoral neck fractures. THA is a useful salvage procedure for failed infected internal fixation of hip fractures. Extreme care must be taken to avoid fracture and penetration of femoral shaft in such cases. Auto graft, allograft and special components like multihole cup, narrow stem should be available for reconstruction in difficult cases

Aims

To establish if COVID-19 has worsened outcomes in patients with AO 31 A or B type hip fractures.