Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures

Background

Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures.

Methods

Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes.

Results

Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45-7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10-4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7-242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation.

Conclusion

Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.

ORTHOPOD: Linking ambulatory future trauma injury distribution from fragility proximal femur fracture caseload

INTRODUCTION

The age of those experiencing traumatic injury and requiring surgery increases. The majority of this increase seen in older patients having operations after accidents is in fragility proximal femur fractures (FPFF). This study designed a model to predict the distribution of fractures suitable for ambulatory trauma list provision based on the number of FPFF patients.

METHODS

The study utilized two datasets which both had data from 64 hospitals. One derived from the ORTHOPOD study dataset, and the other from National Hip Fracture Database. The model tested the predictability of 12 common fracture types based on FPFF data from the two datasets, using linear regression and K-fold cross-validation.

RESULTS

The predictive model showed some promise. Evaluation of the model with mean RMSE and Std RMSE demonstrated good predictive performance for some fracture types, although the r-squared values showed that large variation in these fracture types was not always captured by the model. The study highlighted the dominance of FPFFs, and the strong correlation between these and numbers of ankle and distal radius fractures at a given unit.

DISCUSSION

It is possible to model the numbers of ankle and distal radius fractures based off the number of patients admitted with hip fractures. This has great significance given the drive for increased day case utilisation and bed pressures across health services. While the model's current predictability was limited, with methodological improvements and additional data, a more robust predictive model could be developed to aid in the restructuring of trauma networks and improvement of patient care and surgical outcomes.

The impact of anticoagulant medications on fragility femur fracture care: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

INTRODUCTION

Due to their hypocoagulable state on presentation, anticoagulated patients with femoral fragility fractures typically experience delays to surgery. There are no large, multicentre studies previously carried out within the United Kingdom (UK) evaluating the impact of anticoagulant use in this patient population. This study aimed to evaluate the current epidemiology and compare the perioperative management of anticoagulated and non-anticoagulated femoral fragility fracture patients.

METHODS

Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the United Kingdom. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Main outcomes under investigation included time to surgery, receipt of blood transfusion between admission and 48 h following surgery, length of stay, and 30-day mortality. These were assessed using multivariable linear and logistic regression, and Cox proportional hazards models. Only data from hospitals ≥90 % case ascertainment with reference to figures from the National Hip Fracture Database (NHFD) were analysed.

RESULTS

Data on 10,197 patients from 78 hospitals were analysed. 18.5 % of patients were taking anticoagulants. Compared to non-anticoagulated patients, time to surgery was longer by 7.59 h (95 %CI 4.83-10.36; p < 0.001). 42.41 % of anticoagulated patients received surgery within 36 h (OR 0.54, 95 %CI 0.48-0.60, p < 0.001). Differences in time to surgery were similar between countries however there was some variation across units. There were no differences in blood transfusion and length of stay between groups (OR 1.03, 95 %CI 0.88-1.22, p = 0.646 and 0.22 days, 95 %CI -0.45-0.89; p = 0.887 respectively). Mortality within 30 days of admission was higher in anticoagulated patients (HR 1.27, 95 %CI 1.03-1.57, p = 0.026).

CONCLUSIONS

Anticoagulated femoral fragility fracture patients comprise a substantial number of patients, and experience relatively longer delays to surgery with less than half receiving surgery within 36 h of admission. This may have resulted in their comparatively higher mortality rate. Inclusion of anticoagulation status in the minimum data set for the NHFD to enable routine auditing of performance, and development of a national guideline on the management of this growing and emerging patient group is likely to help standardise practice in this area and improve outcomes.

Fewer native and periprosthetic femoral fracture patients receive an orthogeriatric review and expedited surgery compared to hip fracture patients

INTRODUCTION

Disproportionate emphasis has been attributed to hip fracture over other femoral fractures through implementation of Best Practice Tariff (BPT).This retrospective comparative observational cohort study aimed to evaluate the epidemiology of native and periprosthetic femoral fractures and establish any disparities in their management relative to hip fractures.

METHODS

All patients ⩾60 years admitted with a native or periprosthetic femoral fracture during July 2016-June 2018 were identified using our hospital database. Results were compared to National Hip Fracture Database data over the same period.

RESULTS

58 native femoral, 87 periprosthetic and 1032 hip fractures were identified. (46/58) 79% and 76/87 (89%) of native and periprosthetic femoral fractures were managed operatively. Surgery was performed <36 hours for 34/46 (74%) of native femoral and 33/76 (43%) of periprosthetic fractures compared to 826/1032 (80%) for hips. Median time to surgery was longer in periprosthetic femoral than hip fracture patients (44.7 vs. 21.6 hours; p < 0.0001). Orthogeriatrician review occurred in 24/58 (41%) and 48/87 (55%) of native and periprosthetic fractures compared to 1017/1032 (99%) for hips (p < 0.0001). One year mortality was 35%, 20% and 26% for native femoral, periprosthetic and hip fracture patients. Cox proportional hazard ratio was higher for native femoral than hip fracture patients (1.75; 95% CI, 1.12-2.73).

CONCLUSIONS

This study demonstrates large disparities in management of other femoral and periprosthetic fractures compared to hip fractures, specifically time to surgery and orthogeriatrician review. This may have resulted in the comparatively higher mortality rate of native femoral fracture patients. Expansion of the BPT to include the whole femur is likely to improve outcomes.

Early surgery improves survival after femoral fractures in the elderly: A retrospective review of 502 fragility fractures

AIMS

Fragility fractures are a growing global healthcare burden; fragility fractures of the femur have been shown to occur in a highly comorbid patient group, with parallels to hip fracture patients. This study aimed to investigate if early surgery for femoral fractures, distal to the hip, resulted in a reduction in mortality in patients over 65 years of age.

METHODS

A retrospective review of prospectively collected data for all consecutive femoral fractures in patients aged over 65 years who underwent surgical management between January 2000 and December 2018. Data was extracted from the Fracture Outcomes Research Database (FORD) and analysed to assess if early surgery, defined as occurring within 48 h of hospital admission with a fragility femur fracture, had an effect on 30 day and 1 year mortality.

RESULTS

502 eligible patients were included; median follow up time was 57 months. 24 patients (4.7%) died within 30 days of surgery and 105 patients (20.9%) had died within 1 year of surgery. Patients who underwent surgery within 48 h of admission had a significantly reduced chance of mortality within 1 year of surgery compared to patients who had surgery more than 48 h after admission (OR = 0.401, 95% CI 0.25-0.65, p<0.001). Following Multivariate Cox Regression analysis the hazard ratio of 1 year mortality following early surgery remained significantly reduced (HR = 0.57, 95% CI 0.36-0.92, p = 0.020).

CONCLUSIONS

This study demonstrates that fragility femoral fracture patients represent a similar cohort to hip fracture patients, with high mortality rates. We recommend that hip fracture management principles are also employed for fragility femoral fractures in patients over 65 years, with rapid pre-operative optimisation to ensure these patients undergo early surgical intervention.

Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.