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Background: Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival., Methods: The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization., Results: Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72])., Conclusions: One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The HIP ATTACK-1 trial was supported by the Canadian Institutes of Health Research, the Ontario Strategy for Patient Oriented Research Support Unit, the Ontario Ministry of Health and Long-Term Care, the Hamilton Health Sciences Foundation, the Physicians’ Services Incorporated Foundation, the Michael G. DeGroote Institute for Pain Research and Care, Smith & Nephew (to recruit patients in Spain), and Indiegogo Crowdfunding. This substudy received funding from a McMaster General Internal Medicine Research Grant. Funders had no role in the study design, conduct, analyses, or manuscript preparation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I117)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population., Methods: A population-based, retrospective cohort study was performed on adults (≥60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure., Results: Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001)., Conclusions: Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs., Methods: We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days)., Results: The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours., Conclusions: Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery., Level of Evidence: Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.

Background: Given single-institution studies showing trends between after-hours hip fracture surgical procedures and adverse outcomes, as well as fixation time targets that may increasingly compel after-hours operations, we investigated the relationship between after-hours hip fracture surgical procedures and adverse outcomes in a large, population-based cohort., Methods: All Ontarians who were ≥60 years of age and underwent a hip fracture surgical procedure between April 2002 and March 2014 were eligible for study inclusion. Data were obtained from linked health administrative databases. The primary exposure was after-hours provision of surgical procedures, occurring weekday evenings between the hours of 5 P.M. and 12 A.M. or over the weekend, but not overnight (after 12 A.M. to 7 A.M.). Surgical complications up to 6 months following a hip fracture surgical procedure comprised the primary outcome. Medical complications, including mortality, up to 90 days postoperatively were also assessed. Odds ratios (ORs) were calculated using a logistic regression model that accounted for clustering at the hospital level and adjusted for patient, provider, and fracture characteristics previously shown to explain the majority of variance in hip fracture outcomes., Results: During the study period, 87,647 patients underwent an isolated hip fracture surgical procedure; 51.2% of these patients had femoral neck fractures, 44.1% had intertrochanteric fractures, and 4.7% had subtrochanteric fractures. The surgical procedure occurred after hours in 59,562 patients (68.0%), and 27,240 patients (31.1%) underwent a surgical procedure during normal hours (7 A.M. to 5 P.M.). Only 845 patients (1%) underwent a surgical procedure overnight. We observed no significant relationships between timing of the surgical procedure and adverse outcomes, except for patients who had undergone an after-hours surgical procedure and had fewer inpatient surgical complications (OR, 0.90 [95% confidence interval, 0.83 to 0.99]; p = 0.01)., Conclusions: Adverse outcomes following a hip fracture surgical procedure were similar whether a surgical procedure occurred during normal hours or after hours. Concerns regarding the quality of after-hours surgical procedures should not influence hip fracture prioritization policy. However, given that the great majority of hip fracture surgical procedures occurred after hours, future research should examine other potential consequences of this practice, such as financial impact and surgeon burnout., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Primary closure of skin wounds after debridement of open fractures is controversial. The purpose of the present study was to determine whether primary skin closure for grade-IIIA or lower-grade open extremity fractures is associated with a lower deep-infection rate., Methods: We identified 349 Gustilo-Anderson grade-I, II, or IIIA fractures treated at our level-I academic trauma center from 2003 to 2007. Eighty-seven injuries were treated with delayed primary closure, and 262 were treated with immediate closure after surgical debridement. After application of a propensity score-matching algorithm to balance prognostic factors, 146 open fractures (seventy-three matched pairs) were analyzed., Results: After application of a propensity score-matching algorithm with adjustment for age, sex, time to debridement, American Society of Anesthesiologists (ASA) class, fracture grade, evidence of gross contamination, and a tibial fracture rather than a fracture at another anatomic site, the two treatment groups were compared with respect to the prevalence of infection. Deep infection developed at the sites of three of the seventy-three fractures treated with immediate closure (infection rate, 4.1%; 95% confidence interval [CI], 0.86 to 11.5) compared with thirteen in the matched group of seventy-three fractures treated with delayed primary closure (infection rate, 17.8%; 95% CI, 9.8 to 28.5) (McNemar test, p = 0.0001)., Conclusions: Immediate closure of carefully selected wounds by experienced surgeons treating grade-I, II, and IIIA open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.

Background: The aims of operative treatment of displaced tibial plateau fractures are to stabilize the injured knee to restore optimal function and to minimize the risk of posttraumatic arthritis and the eventual need for total knee arthroplasty. The purpose of our study was to define the rate of subsequent total knee arthroplasty after tibial plateau fractures in a large cohort and to compare that rate with the rate in the general population., Methods: All patients sixteen years of age or older who had undergone surgical treatment of a tibial plateau fracture from 1996 to 2009 in the province of Ontario, Canada, were identified from administrative health databases with use of surgeon fee codes. Each member of the tibial plateau fracture cohort was matched to four individuals from the general population according to age, sex, income, and urban/rural residence. The rates of total knee arthroplasty at two, five, and ten years were compared by using time-to-event analysis. A separate Cox proportional hazards model was used to explore the influence of patient, provider, and surgical factors on the time to total knee arthroplasty., Results: We identified 8426 patients (48.5% female; median age, 48.9 years) who had undergone fixation of a tibial plateau fracture and matched them to 33,698 controls. The two, five, and ten-year rates of total knee arthroplasty in the plateau fracture and control cohorts were 0.32% versus 0.29%, 5.3% versus 0.82%, and 7.3% versus 1.8%, respectively (p < 0.0001). After adjustment for comorbidity, plateau fracture surgery was found to significantly increase the likelihood of total knee arthroplasty (hazard ratio [HR], 5.29 [95% confidence interval, 4.58, 6.11]; p < 0.0001). Higher rates of total knee arthroplasty were also associated with increasing age (HR, 1.03 [1.03, 1.04] per year over the age of forty-eight; p < 0.0001), bicondylar fracture (HR, 1.53 [1.26, 1.84]; p < 0.0001), and greater comorbidity (HR, 2.17 [1.70, 2.77]; p < 0.001)., Conclusions: Ten years after tibial plateau fracture surgery, 7.3% of the patients had had a total knee arthroplasty. This corresponds to a 5.3 times increase in likelihood compared with a matched group from the general population. Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture.