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The aim of the study is to determine the rate of acute kidney injury (AKI) after hip fracture surgery over the age of 80 and to investigate the factors associated with AKI. From January 2015 to January 2020, 589 patients who underwent surgery of hip fractures at our institution were retrospectively reviewed. Serum creatinine (sCr) was analysed daily pre- and postoperatively during the hospital stay. Patients were divided into groups; AKI and non-AKI based on KDIGO (Kidney Disease Global Outcomes) criteria. The incidence, risk factors, and mortality of postoperative AKI were investigated. Out of 589 patients, 58 developed an AKI (9.8%). Smoking (p: 0.004), pre and postoperative low albumin level (p 0.05). AKI is a temporary but common complication following hip fracture surgery, which can also be predicted if risk factors are adequately observed. It typically increases the length of hospital stays, mortality and morbidity. Level III evidence, Retrospective comparative study

Dementia is a common mental disorder that affects the life quality in elders. Recently, emerging studies reported the negative impacts of dementia on prognosis after hip surgeries. However, the integrated and reliable role of dementia in hip surgery is not illustrated. We searched the relevant literatures before June 2020 and extracted the data that met the inclusion criteria. The influence of dementia on postoperative walking ability, complications including infection, cardiovascular complications, hip dislocation, delirium, and respiratory complications, and survival rate at different periods were evaluated. Qualitative and quantitative analysis were conducted using Review Manager Version 5.3. The meta-analysis enrolled a total of 30 studies with 1,037,049 patients. The pooled results revealed that there were significant negative impacts of dementia on the recovery of postoperative walking ability, postoperative infection, hip dislocation, delirium and respiratory complications and mortality at different periods. Dementia is a crucial risk factor for the poor prognosis after hip fracture surgery. Therefore, when making clinical strategies for hip fracture patients with dementia, countermeasures for possible complications should be generated.

A paucity of data exists on safe platelet and international normalized ratio (INR) thresholds for hip fracture surgery. Recent work has called into question the safety of preoperative INRs1.5 for total knee arthroplasty, and optimal platelet thresholds are unknown. The purpose of this study was to identify the risk of 30-day postoperative morbidity and mortality in patients with thrombocytopenia or elevated INRs undergoing hip fracture surgery.The National Surgical Quality Improvement Program database was queried for patients undergoing surgical treatment of a native hip fracture from 2012 to 2017 (N = 86,850). Patient demographic, laboratory, and complication data were collected. Patients with preoperative platelet counts or INRs within one day of surgery were included for analysis. Preoperative platelet counts and INRs were divided into four groups (50 k/μL, ≥50 k to 100 k/μL, ≥100 k to 150 k/μL, ≥150 k/μL, and ≤1.0,1.0 to 1.5,1.5 to 2.0, and2.0, respectively). Multivariable logistic regressions were used to assess the independent association between platelet count and INR on bleeding complications requiring transfusion, wound complications, reoperations, readmissions, and deaths.A total of 72,306 and 56,027 patients were included for analysis of preoperative platelet and INR levels, respectively. In reference to platelet levels ≥150 k/μL, a notably increased risk of bleeding events was observed for patients with platelet counts ≥100 k to 150 k/μL (odds ratio [OR] 1.21, 95% confidence interval 1.15 to 1.27), ≥50 to 100 k/μL (OR 1.85, 1.69 to 2.03), and50 k/μL (OR 1.60, 1.25 to 2.04). Decreasing platelet counts were associated with a stepwise increased risk of mortality from OR 1.12 (1.02 to 1.22) for platelet counts ≥100 k to 150 k/μL to OR 1.63 (1.41 to 1.90) and OR 1.59 (1.06 to 2.39) for platelet counts ≥50 k to 100 k/μL and50 k/μL, respectively. Elevated INR was associated with an increased risk of reoperations, readmissions, and death (P0.001 for all), with largest effect sizes observed starting at INRs1.5.The results of this study suggest that preoperative platelet thresholds of100,000/μL and INR thresholds of 1.5 serve as an important risk factor for complications after hip fracture surgery. Future work is warranted to determine whether preoperative platelet transfusions and/or INR reversal will improve outcomes for these patients.Prognostic Level III.

Hip fractures decrease older adults’ physical activity and quality of life (QoL). However, no current self-efficacy care programs are managed by clinical nurses, and thus no studies have measured their effects on self-care self-efficacy (SCSE). Hence, this quasi-experimental study determined the effectiveness of a self-efficacy care program (SECP) in 104 older adults receiving hip-fracture surgery who were divided into intervention and control groups. The Strategies Used by People to Promote Health and Short Form-36 were administered pre-surgery and at 1 and 3-month intervals post-surgery. The SCSE and QoL of the SECP group were significantly better than the control group at 1- and 3-month follow-ups post-surgery. Both groups’ QoL decreased at one-month post-surgery but increased by 3-months post-surgery. The SECP group had higher psychological QoL than the control group post-surgery. This intervention increased the SCSE and QoL of older adults with hip fractures and improved post-operative care.

BackgroundThe femoral nerve block (FNB) may be used for analgesia in hip fracture surgery. The pericapsular nerve group (PENG) block is a novel regional technique and may provide better pain reduction while preserving motor function, but these blocks have not been directly compared.MethodsIn a single-center double-blinded randomized comparative trial, patients presenting for hip fracture surgery received analgesia with either FNB or PENG block. The primary outcome measure was pain scores (Numeric Rating Scale (NRS) 0 to 10). Secondary outcomes were postoperative quadriceps strength, opiate use, complications, length of hospital stay, and patient-reported outcomes.ResultsSixty patients were randomized and equally allocated between groups. Baseline demographics were similar. Postoperatively in recovery (day 0), the PENG group experienced less pain compared with the FNB group. (In the PENG group, 63% experienced no pain, 27% mild pain, and 10% moderate to severe pain. In comparison, 30% of the FNB group reported no pain, 27% mild pain, and 36% moderate to severe pain; p=0.04). This was assessed using an 11-point Likert NRS. Quadriceps strength was better preserved in the PENG group in the recovery unit (assessed using Oxford muscle strength grading, 60% intact in the PENG group vs none intact in the FNB group; pConclusionsPatients receiving a PENG block for intraoperative and postoperative analgesia during hip fracture surgery experience less postoperative pain in the recovery room with no difference detected by postoperative day 1. Quadriceps strength was better preserved with the PENG block. Despite the short-term analgesic benefit and improved quadriceps strength, there were no differences detected in the quality of recovery.

Background: Dementia patients were reported of having high risk for hip fracture. Rehabilitation programs were still being debated for this vulnerable population and the recovery outcomes in this frail elderly population are varied, thus evidenced-based outcomes for this issue are needed.Objective: To investigate rehabilitation programs, especially on physical function outcomes in patients with dementia following hip fracture surgery.Method: PubMed, Scopus and MEDLINE (EBSCO) databases were searched from January 2000 to June 2020 concerning rehabilitation intervention program in dementia patients who received hip surgical treatment. The studies included have the following criteria, (1) investigating physical outcomes of rehabilitation programs (2) Randomized controlled trials (RCTs) study design, (3) study involving dementia patients following hip fracture surgery (4) English full-text journal.Results: Six studies were included in this review. Most study focused on interdisciplinary or multidisciplinary rehabilitation program. Physical outcomes of rehabilitation programs seem to improve physical function, maintaining physical ability for ambulation, and decrease the risk of falls in mild or moderate dementia patients following hip fracture surgery. However, the physical function of older persons with dementia confirmed to be lower than those without dementia.Conclusion: Rehabilitation may show benefit for physical function in elderlywith mild or moderate dementia following hip fracture surgery, and this population needs to be included in the clinical rehabilitation program. Investigating and establishing the strategies to improve outcomes for dementia population is needed for future study.

To define factors influencing length of hospital stay (LOS) besides surgery delay. We retrospectively analyzed 634 patients operated for hip fractures in 1-year period. Investigated characteristics were age, gender, American Society of Anesthesiologists score (ASA), time to surgery (first 48 h was considered early), type of surgery, anticoagulant therapy and non-routine pre-operative tests. Univariate and multivariable analysis were performed. p values

OBJECTIVE To develop and validate a prediction model for in-hospital mortality in patients with hip fracture 85 years of age or older undergoing surgery. DESIGN A multicenter prospective cohort study. SETTING Six Dutch trauma centers, level 2 and 3. PARTICIPANTS Patients with hip fracture 85 years of age or older undergoing surgery. INTERVENTION Hip fracture surgery. MAIN OUTCOME MEASUREMENTS In-hospital mortality. RESULTS The development cohort consisted of 1014 patients. In-hospital mortality was 4%. Age, male sex, American Society of Anesthesiologists classification, and hemoglobin levels at presentation were independent predictors of in-hospital mortality. The bootstrap adjusted performance showed good discrimination with a c-statistic of 0.77. CONCLUSION Age, male sex, higher American Society of Anesthesiologists classification, and lower hemoglobin levels at presentation are robust independent predictors of in-hospital mortality in patients with geriatric hip fracture and were incorporated in a simple prediction model with good accuracy and no lack of fit. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background There is currently no gold standard instrument for assessing pain in severely cognitively impaired adults who are unable to provide self-report. Aims To determine interrater reliability of the PACSLAC and PAINAD in assessing pain behaviors in patients with the same pain stimulus, determine the consistency of the reliable changes between and within the instruments and assess nurse preference for either instrument. Design A single-group, within-subjects repeated-measures design was implemented. Setting The study took place in a small suburban hospital. Participants/Subjects Pain levels were observed at 24, 48, and 72 hours postsurgery using two instruments: Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Advanced Dementia Scale (PAINAD). These instruments were selected because they are among the most commonly recommended tools for clinical use. Interrater reliability was analyzed along with reliable changes in pain for each period, and the study concluded with the nurse raters completing a preference survey. Methods A convenience sample of 30 patients was used with a diagnosis of severe dementia rendering the patient unable to reliably express pain, 60+ years of age, recovering from hip fracture surgery. Results Greater interrater reliability was found for the PACSLAC, with reliable change potentially affected by the type and level of pain medication. The nurses’ preference for the tool was split. Conclusions The results of this study indicate that the PACSLAC may be the more reliable tool over the PAINAD; however, rater training and familiarity with the tool is critical.

BACKGROUND: Hip fractures are associated with a high rate of morbidity and mortality, and successful ambulation after surgery is an important outcome in this patient population. OBJECTIVE: This study aims to determine whether 25-hydroxyvitamin D [25(OH)D] concentration or the Geriatric Nutritional Risk Index (GNRI) is associated with mortality or rates of walking in a patient cohort after hip fracture surgery. METHODS: Patients undergoing hip fracture repair from a multisite study in North America were included. Mortality and mobility were assessed at 30 and 60 d after surgery. Serum albumin, 25(OH)D, and intact parathyroid hormone were measured. Patients were characterized according to 25(OH)D

Objectives Understand the experience of older adults after hip fracture surgery considering barriers and facilitators related to sedentary behavior. Methods A qualitative study using a semi-structured interview with three men and eight women aged 60 years or older after hip fracture surgery. Results Five barriers emerged: physical complaints, lack of accessibility, fear of falling, demotivation and negative social representation of old age, and two facilitators: overcoming dependency and having a caregiver. Conclusion Our results highlight that physical complaints commonly addressed by physical therapists on their interventions are not the only impediments to reduce sedentary behavior. Important individual and social barriers should not be neglected when physical therapists conduct interventions to reduce sedentary behavior to maximize functional recovery in older adults after hip fracture surgery. Future clinical trials are required to investigate the effectiveness of more comprehensive interventions to reduce sedentary behavior in this population.

Aims This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I2 statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up.

Background: Venous thromboembolic prophylaxis after major orthopaedic surgeries is an essential topic to review and has a lot of controversies and differences regarding which method to emphasize and the duration of each method of prophylaxis to be used in daily practice in orthopaedic surgery.Here we mentioned the review of literature with respect to thromboembolic prophylaxis in orthopaedic surgery including the latest guidelines and we made a meta-analysis of data from many studies regarding the use of different pharmacological agents after major orthopaedic surgeries like total hip replacement (THR), total knee replacement (TKR), hip fracture and knee arthroscopic surgery. Method: we searched Medline via PubMed, SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar from 2010 till November 2019. The search retrieved 2089 unique records. We then retained 57 potentially eligible records for full-texts screening. Finally, 29 studies were included. Results: the rate of DVT was higher with DTI than with LMWH and lowest with FXaI, while the rate of PE was higher with DTI than FXaI and lowest with LMWH. The rate of major bleeding was higher with LMWH than with FXaI and lowest with DTI, indicating that FXaI has the lead in thromboembolic prophylaxis after THR or TKR with lower risk of bleeding compared to LMWH. Conclusion: FXaI was the most effective agent after THR and TKR. In hip fracture surgery and Knee arthroscopy, thromboprophylaxis is needed, but variable results regarding the drug choice warrant more research.

The recent focus on early surgery for hip fractures to reduce complications and improve morbidity, has led some resource-constrained institutions to perform after hours surgery in a bid to meet these timelines. However, there are concerns about the potential increase in complications and poorer outcomes in after hours surgery. This study aims to evaluate the safety of after hours hip fracture surgery and its related complications. This is a retrospective review of hip fracture patients admitted over a 2-year period to a tertiary centre with an established orthogeriatric co-managed hip fracture care pathway. Patients were divided into two groups based on their operating start time: (1) office hours surgery was defined as surgery conducted between 8 am to 5 pm on weekdays and 8 am to 12 noon on Saturdays; and (2) after hours surgery was defined as surgery conducted between 5 pm to 8 am on weekdays, and between Saturday 12 noon to Monday 8 am, as well as those that were conducted on public holidays. Demographic data, comorbidities, fracture details, operative details and outcome measures (complications, mortality and functional scores) were collated. A total of 903 patients were surgically treated for per- and intertrochanteric or femoral neck fractures. 76.7% (n = 693) of the patients underwent operation during office hours while 23.3% (n = 210) of the patients underwent after hours operation. 12.4% (n = 26) of the after hours group underwent surgery within 24 h of admission, compared with 6.8% (n = 47) in the office hours group (p = 0.009). We did not find any significant difference between the two groups in terms of complications, mortality and functional outcomes (p > 0.05). In conclusion, our study did not show that after hours surgery increases complication rates in hip fracture surgery and had equivalent functional outcomes.

Introduction This study aimed to investigate the effects of a home-based occupational therapy telerehabilitation (TR) via smartphone in enhancing functional and motor performance and fall efficacy for outpatients receiving day hospital rehabilitation after hip fracture surgery in Hong Kong. Methods This was a feasibility randomised controlled trial with two groups – an experimental group and a comparison group – and a sample of 31 older adults attending a geriatric day hospital who had undergone hip fracture surgery within 12 weeks of diagnosis. Patients were assessed at baseline, immediately after a three-week intervention and at three-week post-intervention follow-up for motor performance, activities of daily living (ADL) functioning and fall efficacy. The experimental group received a home programme using the Caspar Health e-system and a mobile app for smartphones, while the comparison group received paper-and-pencil instructions for the home programme on a weekly basis for three weeks. Results Compared to the comparison group, significant improvements in fall efficacy and instrumental ADL performance at post intervention and follow-up were found in the experimental group. However, in the comparison group, inadequate social support was a factor contributing to better muscle strength testing in both the affected and non-affected legs. There were no significant differences between the two groups in regard to the other variables. Discussion This study supports the potential use of TR via smartphone as an alternative home programme for use in occupational therapy practice with older adults after hip fracture surgery.

Few information exist about incidence and prognostic significance of postoperative atrial fibrillation (POAF) in patients undergoing hip fracture surgery. In the period comprised between January 2012 and December 2016, we evaluated 3129 patients referred for hip fracture. At hospital admission 277 were in permanent atrial fibrillation and were excluded from the study. POAF was defined as symptomatic or asymptomatic AF of duration > 10 min occurring during hospitalization after hip surgery. In-hospital and 1-year outcomes of POAF patients were compared to that of an age- and sex-matched hip fracture control group. Survival rates were estimated by Kaplan–Meier curves and differences between groups compared by log-rank test. One hundred and four patients (mean age 83.7 years, men 27%) developed POAF (3.6%). Time of onset after surgery was on average 2 days after surgery. Eight POAF patients died during hospitalization. 81.7% were discharged in sinus rhythm. Patients with POAF had a longer time to surgery (3.8 ± 3.3 vs. 2.4 ± 1.6 days, p = 0.0007) and length of hospital stay (19.7 ± 10.4 vs. 14.4 ± 5.1 days p

Background To compare the muscle strength of patients with a hip fracture according to the presence of sarcopenia after surgery and the correlation of measured values between a Biodex and surface electromyography (sEMG) in postoperative measurement of muscle strength. Methods Seventy-one patients who underwent hip fracture surgery were included in this study. Muscle mass was measured using dual energy X-ray absorptiometry and the grip strength was evaluated using a dynamometer. The diagnosis of sarcopenia followed the Asian Working Group for Sarcopenia criteria. We evaluated the Biodex to assess muscle strength according to the presence of sarcopenia and at the same time measured the sEMG to evaluate the correlation of muscle strength between Biodex and sEMG. Results We assigned 34 patients with sarcopenia and 37 without sarcopenia to 2 groups. In the comparison of muscle strength using Biodex and sEMG between the 2 groups, it was confirmed that muscle strength of sarcopenia group was decreased compared with that of the non-sarcopenia group, although there was no statistical significance between the groups. However, Biodex and sEMG showed very close correlation with muscle strength in all variables. Conclusions We suggest that using sEMG for the evaluation of muscle strength after hip fracture surgery may be an excellent tool alternative to isokinetic testing machines such as the Biodex.

Xuepan Chen,1,2,* Yuanchen Ma,1,* Zhantao Deng,1 Qingtian Li,1 JunXing Liao,1 Qiujian Zheng1 1Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China; 2Shantou University Medical College, Shantou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Qiujian ZhengDepartment of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, School of Medicine, South China University of Technology, No. 106, Zhongshan Second Road, Yuexiu District, Guangzhou 510000, People’s Republic of ChinaEmail zqj106@126.comIntroduction: Transthoracic echocardiography (TTE) is a common cardiac screening test before hip fracture surgery. However, the general TTE test delays surgery, so it would be meaningful if we could simplify the TTE by only assessing cardiac abnormality specifically. Therefore, we aimed to establish the most clinically relevant abnormality by comparing the predictive value of each major cardiac abnormality in postoperative cardiac complications and mortality in elderly hip fracture patients.Patients and Methods: From January 2014 to January 2019, the medical records of all surgically treated elderly patients (> 65 years) with hip fracture were analyzed. The major TTE abnormalities were defined as left ventricular hypertrophy, systolic pulmonary arterial pressure > 25 mm Hg, moderate-severe valve abnormality, left ventricular ejection fraction (LVEF) < 50%, and pericardial effusion. The outcomes were postoperative cardiac complications and in-hospital mortality.Results: There were 354 patients involved finally. Postoperative cardiac complications were encountered in 7.6% (n=27) of patients. The mortality rate was 2.8% (n=10). History of coronary artery disease (CAD) (OR: 3.281, 95% CI: 1.332– 8.079, p=0.010) and presence of aortic stenosis (AS) (OR:5.656, 95% CI: 1.869– 17.117, p=0.002) were independent predictors of postoperative cardiac complications. In addition, age (OR: 1.264, 95% CI: 1.047– 1.527, p=0.015), history of CAD (OR: 19.290, 95% CI: 2.002– 185.885, p=0.010), presence of AS (OR:7.164, 95% CI: 1.988– 51.413, p=0.040) and LVEF < 50% (OR:8.803, 95% CI: 1.115– 69.472, p=0.039) were independent predictors of mortality. However, the rest of preoperative TTE abnormalities were not associated with postoperative cardiac complications or mortality.Conclusion: Among the TTE abnormalities presented by elderly patients with hip fracture, moderate-severe AS was the predictor of postoperative cardiac complications. Moreover, moderate-severe AS and LVEF < 50% were the predictors of in-hospital mortality. Therefore, we could simplify the TTE process by assessing aortic valve and LVEF specifically on focused echocardiography, which could avoid surgery delay.Keywords: aging, hip fracture surgery, mortality, postoperative cardiac complications, echocardiographic abnormality

Objective: to point the positive impact of early surgery (performed within 48 hours) and non-general anesthesia techniques on early outcomes like in-hospital mortality and length of hospital stay (LOS). Methods: seven hundred and ten patients were included in this retrospective study. Patients aged 50 years and over, who were admitted to our hospital with hip fracture, were included, while the patients with pathological fractures or polytraumatic injuries were excluded. Results: the median age of the patients was 75.8 +/- 10,.3 years. Four hundred and sixty-nine (66.1%) patients were female. Six hundred and eighty-two patients (96.1%) were treated surgically, 16 patients (2.25%) received conservative treatment and 12 patients (1.7%) died before scheduled surgery. General anesthesia (n=328), spinal anesthesia (n=268), unilateral spinal anesthesia (n=47), peripheral nerve block (n=29), and combined spinal-epidural (CSE) anesthesia (n=10) were the anesthesia techniques used for surgery. Patients who were treated within 48 hours (G1) had lower in-hospital mortality than the patients who were treated lately (G2) (0.8% vs 4,7%). The LOS for G1 was 8.6 days whereas it was 17.5 days for G2 (p, Toranomon Hospital; Okinaka Memorial Institute for Medical Research; Gout Research Foundation in Japan

Background and Purpose: Two medical specialties, general surgery and orthopaedic surgery, with different training programs but matching trauma certification requirements, provide hip fracture surgery in the Netherlands. This study analyses treatment preferences and guideline adherence of Dutch surgeons with different surgical backgrounds.Patients and Methods: All hip fracture patients registered in the Dutch Hip Fracture Audit in 2018 and 2019 were included in this retrospective study. Four types of surgeons were distinguished: trauma-certified general surgeons (ST+), non-trauma certified general surgeons (ST-), trauma-certified orthopaedic surgeons (OT+) and non-trauma certified orthopaedic surgeons (OT-). Differences in patient characteristics, and practice variation in treatment choices and guideline adherence per fracture type were analysed using descriptive statistics.Results: 28,656 patients were included; 16,367 (57.1%) treated by ST +, 1,371 (4.8%) by ST-, 4,692 (16.4%) by OT+ and 6,226 (21.7%) by OT-. Few clinically relevant differences in patient characteristics and hospital processes were found between all surgeon groups. Displaced FNF were the most commonly treated fracture type for all types of surgeons. Both OT+ and OT- operated mostly (displaced) FNFs, while the fracture types treated by ST+ and ST- were more heterogeneous. For all fracture types, the orthopaedic surgeons performed THA and HA more often than general surgeons, while general surgeons more often placed SHS and IMN for specific fracture types. Guideline adherence was on average 68.4% and differed significantly per surgeon type (68.7% by ST+, 65.2% by ST-, 74.4% by OT+ and 63.6% by OT-(p90% treatment according to the guideline for trochanteric AO-31A2 and A3 fractures, 18.8% for AO-31A1 fractures and 51.7% guideline adherence for undisplaced FNF. Guideline adherence for displaced FNF varied depending on patient characteristics.Discussion: In the Netherlands, different surgical specialists treat different types of hip fractures and have different preferences concerning implants for hip fracture surgery in comparable patients. Guideline adherence of trauma- and non-trauma certified orthopaedics and general surgeons differs significantly. Reduction of practice variation should be strived for in order to improve hip fracture care. (C) 2021 The Authors. Published by Elsevier Ltd.

Introduction Early mobilisation leads to a two-fold increase in the odds of discharge by 30-days compared to late mobilisation. Whether this association varies by identified reasons for delayed mobilisation is unknown. Methods Audit data linked to hospitalisation records for patients 60 years or older surgically treated for hip fracture in England/Wales 2014–2016. Adjusted proportional odds regression models tested whether the cumulative incidences of discharge differed for early compared with late mobilisation across subgroups defined by dementia, delirium, hypotension, prefracture ambulation and residence, accounting for competing risk of death. Results Overall, 34,253 patients presented with dementia, 9,818 with delirium, and 10,123 with hypotension. Prefracture, 100,983 were ambulant outdoors, 30,834 were ambulant indoors only, 107,144 were admitted from home, and 23,588 from residential care. 10%, 8%, 8%, 12%, and 12% fewer patients with dementia, delirium, hypotension, ambulant indoors only prefracture, or from residential care mobilised early compared to those without dementia, delirium, hypotension, with outdoor ambulation prefracture, or from home. Adjusted odds ratios of discharge by 30-days for early compared with late mobilisation were 1.71 (95% CI 1.62–1.81) for those with dementia, 2.06 (95% CI 1.98–2.15) without dementia, 1.56 (95% CI 1.41–1.73) with delirium, 2.00 (95% CI 1.93–2.07) without delirium, 1.83 (95% CI, 1.66–2.02) with hypotension, 1.95 (95% CI, 1.89–2.02) without hypotension, 2.00 (95% CI 1.92–2.08) with outdoor ambulation prefracture, 1.80 (95% CI 1.70–1.91) with indoor ambulation only prefracture, 2.30 (95% CI 2.19–2.41) from home, and 1.64 (95% CI 1.51–1.77) from residential care. Conclusion Irrespective of dementia, delirium, hypotension, prefracture ambulation or residence, early compared to late mobilisation increased the likelihood of discharge by 30-days. Fewer patients with these conditions, poorer prefracture ambulation, or from residential care mobilised early. There is a need reduce this care gap by ensuring sufficient resource to enable all patients to benefit from early mobilisation.

Background: Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF.Materials and Methods: We searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH.Results: The search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25-1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding.Conclusions: Meta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH. (C) 2021 The Authors. Published by Elsevier Ltd.

Summary: Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture. Introduction: To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital. Methods: We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death. Results: The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19–1.30) and 1.26 (95% CI 1.19–1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18–1.52) and 1.33 (95% CI 1.12–1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08–1.15) and 1.10 (95% CI 1.05–1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge. Conclusion: We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6–7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.

Introduction: Postoperative day 1 (POD1) mobilisation is a key clinical indicator for the fragility hip fracture surgery population. This study aimed to evaluate the current trends of POD1 mobilisation at our institution; and to review the relationships between early mobilisation and outcomes of early functional recovery, length of stay (LOS) and discharge destination. Methods: In this preliminary observational study, data pertaining to demographics, pre-morbid function, health status, injury and surgical factors, POD1 mobilisation status and clinical outcomes of interest were retrieved from eligible patients. Patients who attained POD1 ambulation formed the “Early Ambulation (EA)” Group while the remaining patients formed the “Delayed Ambulation (DA)” group. Data were analysed for any significant difference between the groups. Results: 115 patients were included in the analysis. The rate of patients achieving at least sitting out of bed on POD1 was 80.0% (92 patients) which was comparable with data available from international hip fracture audit databases. 55 patients (47.8%) formed the EA group and 60 patients (52.5%) formed the DA group. EA group was approximately nine times more likely to achieve independence in ambulation at discharge compared to the DA group (adjusted odds ratio 9.20; 95% Confidence Interval 1.50-56.45; p = 0.016). There were observed trends of shorter LOS and more proportion of home discharge in the EA group compared to DA group (p > 0.05). Conclusion: This is the first local study to offer benchmark of the POD1 mobilisation status for this population. Patients who attained POD1 ambulation had better early functional recovery.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of pharmacological or mechanical interventions, or both combined, for the primary prevention of venous thromboembolism in individuals undergoing hip fracture surgery.

Aims The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures. Methods This was a retrospective analysis of publicly available audit data obtained from the National Hip Fracture Database (NHFD) 2018 benchmark summary and Facilities Survey. Data extraction was performed using a dedicated proforma to identify relevant hospital-level care process and outcome variables for inclusion. The primary outcome measure was adjusted 30-day mortality rate. A random forest-based multivariate imputation by chained equation (MICE) algorithm was used for missing value imputation. Univariable analysis for each hospital level factor was performed using a combination of Tobit regression, Siegal non-parametric linear regression, and Mann-Whitney U test analyses, dependent on the data type. In all analyses, a p-value < 0.05 denoted statistical significance. Results Analyses included 176 hospitals, with a median of 366 hip fracture cases per year (interquartile range (IQR) 280 to 457). Aggregated data from 66,578 patients were included. The only identified hospital-level variable associated with the primary outcome of 30-day mortality was hip fracture trial involvement (no trial involvement: median 6.3%; trial involvement: median 5.7%; p = 0.039). Significant key associations were also identified between prompt surgery and presence of dedicated hip fracture sessions; reduced acute length of stay and both a higher number of hip fracture cases per year and more dedicated hip fracture operating lists; Best Practice Tariff attainment and greater number of hip fracture cases per year, more dedicated hip fracture operating lists, presence of a dedicated hip fracture ward, and hip fracture trial involvement. Conclusion Exploratory analyses have identified that improved outcomes in hip fracture may be associated with hospital-level service characteristics, such as hip fracture research trial involvement, larger hip fracture volumes, and the use of theatre lists dedicated to hip fracture surgery. Further research using patient level data is warranted to corroborate these findings. Cite this article: Bone Joint J 2021;103-B(10):1627–1632.

BackgroundPrevious studies have shown increased risk of fracture in older patients with poor or strict glycemic control (glycated hemoglobin, HbA1c, ≥ 8% or < 6-7% respectively); however, these reports did not investigate the oldest-old population. Comprehensive geriatric assessment (CGA) and a patient-centered approach have been proven to improve the quality of care in the management of Type 2 Diabetes Mellitus (T2DM) in the older patients, but data regarding T2DM in patients with fragility fractures are still lacking.AimTo investigate the prognostic role of HbA1c and frailty level in older diabetic patients admitted for hip fracture.MethodsProspective observational cohort study conducted on diabetic geriatric patients consecutively hospitalized for hip fracture in the orthogeriatric unit of a tertiary care hospital. Preoperative comprehensive geriatric assessment (CGA) was performed. Using the Clinical Frailty Scale (CFS), diabetic patients were categorized in robust (CFS < 5) and frail (CFS ≥ 5), and further stratified according to HbA1c values [Tertile 1 (T1) HbA1c < 48 mmol/mol, Tertile 2 (T2) 48-58 mmol/mol and Tertile 3 (T3) > 58 mmol/mol). Comparisons between continuous variables were performed with analysis of non-parametric test for independent samples, while relationships between categorical variables were assessed by chi-square test. Using logistic multivariate regression, we evaluated the determinants of 1-year all-cause mortality in diabetic older patients with hip fracture.ResultsAmong the 1319 older patients (mean age 82.8 ± 7.5 years, 75.9% females) hospitalized for hip fracture, 204 (15.5%) had a previous diagnosis of T2DM. T2DM patients showed an increased proportion of multiple concurrent fractures occurred during the accidental fall or syncope (12.7% vs 11.2%, p=0.02). One-year mortality after hip fracture surgery was significantly higher in T2DM as compared to not diabetic patients (21.2% vs 12.5%, pvs 5%, p=0.001 for T2 and 43.5% vs 13.3%, p=ConclusionsFrail patients with HbA1c ≥ 48 mmol/L showed an increased mortality risk as compared to robust counterparts. CFS represents an important tool to select diabetic subjects with higher likelihood of adverse outcome.

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.

Proximal femoral fractures (often denoted as hip fractures) are amongst the most prevalent fractures in older patients and associated with significant mortality and morbidity.Failure to recover to prefracture levels of function has important social and economic implications, as these patient’s risk losing their independence and self-reliance. The primary aim of this thesis is to provide a better understanding of the factors relevant for the functional prognosis of patients with a proximal femoral fracture.This thesis covers two parts, focusing on the effects of surgical aspects and patient demographics.​​​​​​​Outcomes of previously performed studies on prognostic factors of recovery proved hard to compare. This can be attributed to the high level of heterogeneity and methodology of these studies, for instance in the method to objectify recovery. For the studies in this thesis, we have opted to compare outcomes with the patients’ individual prefracture level of function. Surgical aspects, such as different approaches to place a prosthesis, seemed to have a reserved effect on recovery. Factors which seemed of conclusive relevance were health scores based on the comorbidity and prefracture level of function. This emphasizes the importance of a holistic and geriatric approach for patients with proximal hip fractures.

Aim To assess whether this change of practice had an effect on the infection rate in hip fracture surgery. Method An audit was conducted to assess the re-operation rate on hip fracture patients over the three months of the initial “lockdown” (23rd March to 23rd May 2020) and compared to the 2 months immediately before and the same period in 2019. Cases were identified from the Theatre ORACLE system (GE Healthcare). Anonymised patient data was collected from the Electronic Patient Record (EPR) and paper case notes. Results During the pandemic period, a total of 45 patients underwent surgery for hip fractures with a median age 84 years (range 28-95 years). These represent similar cohorts to the periods immediately before lockdown and the previous year. The infection rate increased from 0% in the 2019 period to 2.5% prior to lockdown and 11.1% after the lockdown measures were implemented. All infections were in patients who received hemiarthroplasty. The rate of total hip replacement went down from 19.1% in 2019 to 10.0% just before the pandemic and just 4.4% during the pandemic Conclusions There was a marked increase in the number of re-operations for infection in patients who received hemiarthroplasty for hip fractures during the lockdown period.

Objective To determine if there is a difference in the rate of early infection in hip fracture surgery performed under laminar flow and conventional turbulent ventilation. Method The impact on the rates of early surgical site infection (SSI) in patients who sustained a hip fracture after our trauma theatre was moved from a laminar to a non-laminar flow theatre was assessed. Data was retrospectively collected for six months prior to the merging of the trauma service and six months after. For each operation: age, gender, American Society of Anesthesiologists (ASA) grade, dementia, diabetes, immunosuppressants, anticoagulation, smoking status, duration of surgery, administration of peri-operative antibiotics, surgeon grade, skin closure method, and SSI were extracted from the hospital electronic notes with input from the trust's SSI surveillance team. Results 259 hip fracture operations were performed during this period. Seven patients were excluded due to incomplete information. There were 95 patients in the laminar flow group and 157 in the non-laminar flow group. There were no SSIs in the laminar flow group and a 3.2% SSI rate (Fishers exact p = 0.16) in the non-laminar flow group. Three were superficial infections and two deep. This difference was not statistically significant. Patient characteristics were included in a Firth logistic regression model which did not show a significant change in the odds ratio. Conclusion A higher incidence of early SSI was found when hip fracture surgery was performed under non-laminar flow conditions but this difference was not statistically significant. Larger studies may change this outcome.

Objective To investigate the correlation between mechanography and clinical parameters in older people at 3 and 6 months after hip fracture surgery. Methods A longitudinal follow-up study was conducted in university hospitals with 38 patients at 3 months and 29 patients at 6 months after hip fracture surgery. Subjects 65 years and older completed measurements on the Berg Balance Scale (BBS), Functional Ambulation Category (FAC), walking ability by Koval, Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight (K-FRAIL) scale, and hand grip strength. The Romberg test with center of foot pressure (COP), chair rise test (CRT), and maximal power (W/kg) were conducted using the Leonardo Mechanograph. Results COP area and pathway length were correlated with BBS at 3 and 6 months. Change in BBS was correlated with change in COP area, but not with change in COP length. COP area and pathway length were correlated with K-FRAIL at 3 months after hip fracture surgery. The same COP variables showed correlations with FAC and walking ability by Koval at 6 months after surgery. Maximal power during CRT had correlation with chair rise time but not with other clinical parameters. Conclusion The study revealed correlations between mechanography and clinical parameters in older people at 3 and 6 months after hip fracture surgery. Both the clinical assessment and objective test with mechanography may be required for the quantitative and sensitive measurement of postural balance and lower limb muscle power.

Introduction Fear of Falling (FoF) is common after hip fracture and associated with adverse outcomes including impaired functional recovery and recurrent falls. The objective of this study was to measure self-efficacy related to falls and its association with functional outcomes after hip fracture surgery. Methods A prospective cohort study was performed on 106 community-dwelling elderly aged ≥65 years without dementia, admitted to a community hospital for rehabilitation after surgery for fragility hip fracture in Singapore. They were managed in an integrated multidisciplinary orthogeriatric programme, transitioning from acute orthopaedic unit to the affiliated community hospital. Falls Efficacy Scale (FES; range 10-100) was assessed on discharge. Main outcomes measured included Parker Mobility Score (PMS) and Modified Barthel Index (MBI) at 3 months. Results Key characteristics of the cohort were: mean age 79.4(SD 6.38); female 74%, Chinese 83%, pre-fracture PMS 6.7(SD 2.7); pre-fracture MBI 81.1(SD 20.9); mean FES score 32.0(SD 23.7). At 3 months, mean PMS was 3.97(SD 2.51); mean MBI was 73(SD 20.1), demonstrating that the cohort overall did not regain their pre-morbid functional levels. FES was negatively correlated with both 3-month MBI and PMS with coefficients -0.592 and -0.523 respectively (p Conclusion FoF is a potentially modifiable factor linked to adverse functional outcomes in hip fracture rehabilitation, indicating the necessity to address falls self-efficacy as a major component of assessment and intervention, whilst further exploring the local validity and applicability of various instruments measuring FoF. Further studies need to be conducted on the evolving patterns of FoF over time and its impact on longer-term functional and psychosocial outcomes.

Background A hip fracture is an unexpected, subjective, traumatic experience that affects the person in both physical and emotional ways. Purpose The purpose of this study was to describe rural older people's experiences of recovering after hip fracture surgery. Methods Thirteen individual interviews were conducted with older people. The interview texts were analyzed with qualitative content analysis. Results Patients described finding themselves in a new and vulnerable situation, dependent on others for simple everyday chores. They struggled to regain independence while staying positive, convinced that they would recover. Fear of another fall, as well as lack of information, made recovery at home difficult. Conclusion Older people who experience hip fractures need support during the recovery process. Because recovery begins at the hospital, this study highlight patients' need to participate in recovery planning, as well as the need to have information about what it means to be affected by a hip fracture and how to prevent it from happening again. This study emphasizes that nurses' awareness of patients' need to participate in planning the recovery process is crucial for enabling patients' return to a daily life that is similar to their prefracture life.

Reducing functional decline is an essential treatment goal in older adults after hip fracture surgery. The current study examined different effects of functional decline–related factors according to activities of daily living (ADL) and instrumental ADL (IADL) in older adults after hip fracture surgery. A total of 120 participants were included. In quantile regression, preoperative walking and fear of falling were significantly associated with ADLs in the 25th percentile ADL group. Fear of falling was the only significant factor in the poorest IADL group (25th percentile). Efforts should be made to reduce fear of falling after hip fracture surgery. Preoperative walking status was significant in patients with poor ADL after hip fracture surgery; therefore, walking status should be taken into consideration when planning rehabilitation care in this group, so that the best possible ADL outcomes can be attained. [Research in Gerontological Nursing, 12 (6),312–320.]

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Adverse outcomes and resource use rates are high after hip fracture surgery. Peripheral nerve blocks could improve outcomes through enhanced analgesia and decreased opioid related adverse events. We hypothesized that these benefits would translate into decreased resource use (length of stay [primary outcome] and costs), and better clinical outcomes (pneumonia and mortality). Methods The authors conducted a retrospective cohort study of hip fracture surgery patients in Ontario, Canada (2011 to 2015) using linked health administrative data. Multilevel regression, instrumental variable, and propensity scores were used to determine the association of nerve blocks with resource use and outcomes. Results The authors identified 65,271 hip fracture surgery patients; 10,030 (15.4%) received a block. With a block, the median hospital stay was 7 (interquartile range, 4 to 13) days versus 8 (interquartile range, 5 to 14) days without. Following adjustment, nerve blocks were associated with a 0.6-day decrease in length of stay (95% CI, 0.5 to 0.8). This small difference was consistent with instrumental variable (1.1 days; 95% CI, 0.9 to 1.2) and propensity score (0.2 days; 95% CI, 0.2 to 0.3) analyses. Costs were lower with a nerve block (adjusted difference, −$1,421; 95% CI, −$1,579 to −$1,289 [Canadian dollars]), but no difference in mortality (adjusted odds ratio, 0.99; 95% CI, 0.89 to 1.11) or pneumonia (adjusted odds ratio, 1.01; 95% CI, 0.88 to 1.16) was observed. Conclusions Receipt of nerve blocks for hip fracture surgery is associated with decreased length of stay and health system costs, although small effect sizes may not reflect clinical significance for length of stay.