Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Hip Fracture

The Impact of Hospital Volume and Region on Mortality, Medical Costs, and Length of Hospital Stay in Elderly Patients Following Hip Fracture: A Nationwide Claims Database Analysis

Backgroud

The purpose of our study was to analyze the effects of hospital volume and region on in-hospital and long-term mortality, direct medical costs (DMCs), and length of hospital stay (LOS) in elderly patients following hip fracture, utilizing nationwide claims data.

Methods

This retrospective nationwide study sourced its subjects from the Korean National Health Insurance Review and Assessment Service database spanning from January 2011 to December 2018. A generalized estimating equation model with a Poisson distribution and logarithmic link function was used to estimate adjusted odds ratios (aORs) and 95% CIs to assess the association of hospital volume with in-hospital and 1-year mortality, DMCs, and LOS.

Results

A total of 172,144 patients were included. Comparing the risk of in-hospital death between high-volume and low-volume hospitals, the risk of in-hospital death was 1.2 times higher at low-volume hospitals (aOR, 1.20; 95% CI, 1.07-1.33; p = 0.002). Additionally, the risk of death at 1 year was 1.05 times higher at low-volume hospitals (aOR, 1.05; 95% CI, 1.01-1.09; p = 0.008) compared to high-volume hospitals. DMCs were 0.84 times lower at low-volume hospitals for in-hospital period (aOR, 0.84; 95% CI, 0.84-0.85; p < 0.001) and 0.87 times lower for 1 year (aOR, 0.87; 95% CI, 0.86-0.88; p < 0.001) compared to high-volume hospitals. In-hospital LOS was 1.21 times longer at low-volume hospitals (aOR, 1.21; 95% CI, 1.20-1.22; p < 0.001) than at high-volume hospitals. In addition, the risk of in-hospital death was 1.22 times higher (aOR, 1.22; 95% CI, 1.12-1.33; p < 0.001) and the risk of 1-year death was 1.07 times higher (aOR, 1.07; 95% CI, 1.04-1.10; p < 0.001) at rural hospitals compared to urban hospitals.

Conclusions

Clinicians should focus on improving clinical outcomes for hip fracture patients in low-volume and rural hospital settings, with a specific emphasis on reducing mortality rates.

Prevalence of complications in older adults after hip fracture surgery : a systematic review and meta-analysis

Aims

Older adults with hip fractures are at high risk of experiencing complications after surgery, but estimates of the rate of specific complications vary by study design and follow-up period. The aim of this systematic review was to determine the prevalence of complications in older adults after hip fracture surgery.

Methods

MEDLINE, Embase, CINAHL, and CENTRAL databases were searched from inception until 30 June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (aged ≥ 60 years) undergoing hip fracture surgery.

Results

A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications, the 30-day prevalence of reoperation was 2.31%, surgical site infection 1.69%, and deep surgical site infection 0.98%; the 365-day prevalence of prosthesis dislocation was 1.11%, fixation failure 1.77%, and periprosthetic or peri-implant fracture 2.23%. For general complications, the 30-day prevalence of acute kidney injury was 1.21%, blood transfusion 25.55%, cerebrovascular accident 0.79%, lower respiratory tract infection 4.08%, myocardial infarction 1.98%, urinary tract infection 7.01%, and venous thromboembolism 2.15%.

Conclusion

Complications are prevalent in older adults who have had surgery for a hip fracture. Studies reporting complications after hip fracture surgery varied widely in terms of quality, and we advocate for the routine monitoring of complications in registries and clinical trials to improve the quality of evidence.

Association Between Nail Type and Aseptic Revision Risk After Cephalomedullary Nailing for Hip Fracture

BACKGROUND

Although the majority of intertrochanteric femoral fractures in the United States are now treated with cephalomedullary nailing, it remains uncertain whether differences in clinical performance by nail type exist. The purpose of this study was to compare the aseptic revision rates associated with the 3 most commonly utilized cephalomedullary nails in the United States today: the Gamma nail (Stryker), the INTERTAN (Smith+Nephew), and the Trochanteric Fixation Nail/Trochanteric Fixation Nail Advanced (TFN/TFNA; DePuy Synthes).

METHODS

Using an integrated health-care system's hip fracture registry, patients ≥60 years of age who were treated with 1 of these 3 commonly used cephalomedullary nail devices were identified. Potential confounders were identified and controlled for, including age, gender, race or ethnicity, body mass index, smoking status, American Society of Anesthesiologists classification, anesthesia type, Elixhauser comorbidities, and the operating surgeon. Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision (the primary outcome measure) by cephalomedullary nail type, with mortality and revisions unrelated to the index fracture considered as competing events.

RESULTS

There were 19,215 patients included in the study sample (71.4% female, 77.0% White), including 4,421 in the Gamma nail group, 2,350 in the INTERTAN nail group, and 12,444 in the TFN/TFNA nail group. In the multivariable analysis involving nails of all lengths, the INTERTAN group was found to have a higher risk of aseptic revision compared with the TFN/TFNA group (8-year crude revision rate, 2.9% compared with 1.8%; hazard ratio [HR], 1.62 [95% confidence interval (CI), 1.15 to 2.27]; p = 0.006). The increased risk associated with the INTERTAN nail was primarily seen among the long nails (HR, 1.83 [95% CI, 1.16 to 2.87]; p = 0.009) rather than the short nails (HR, 1.36 [95% CI, 0.87 to 2.11]; p = 0.18). There were no differences in aseptic revision observed between the Gamma group and the TFN/TFNA group.

CONCLUSIONS

In this study of 19,215 patients with a hip fracture treated with cephalomedullary nailing, the INTERTAN nail was found to have a significantly higher risk of aseptic revision. Further research is required to determine whether these results could be related to the unique design of this implant.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low-Cost Task Trainer for In Utero Fetal Stent Placement

INTRODUCTION

Some fetal procedures such as intrauterine fetal stent placement remain rare, and simulation is needed to help learners and specialists in attaining and maintaining technical competence. We sought to design and assess a low-cost, easily assembled yet clinically relevant task trainer for fetal stent placement.

METHOD

The simulator was constructed using 2 quart-sized freezer bags filled with ultrasound gel and sealed with clear packing tape. The bags were stacked vertically in a transparent plastic container with ultrasound gel applied between the bags when ultrasound was used. This task trainer was used to deploy in utero stents with or without the use of ultrasound. It has been used at the annual meeting of the Society for Maternal-Fetal Medicine since 2015, the annual meeting of the International Society of Ultrasound in Obstetrics and Gynecology in 2015 and 2016, and at regional Maternal-Fetal Medicine Fellow simulation workshops since 2016. Participants were asked to complete a 5-point Likert scale survey regarding the model's realism and usefulness in training.

RESULTS

One hundred thirty-three course participants evaluated the task trainer. The median rating for realism of the ultrasound images, haptic feel of stent deployment, and usefulness in training was 5 (interquartile range, 4-5). Seven physicians participated in the timed assessment of model assembly, stent deployment, and model reassembly. The average times required for the freezer bag task trainer were 2.3 minutes (2.20-2.35), 1.0 minutes (0.70-1.93), and 0.1 minutes (0.08-0.10), respectively. For the porcine tissue-based model tested in parallel, the average times were 6.0 minutes (5.00-7.06), 3.7 minutes (3.63-3.75), and 3.3 minutes (3.00-3.70), respectively.

CONCLUSIONS

This low-cost simulator was rated highly when used to practice in utero stent deployment and allows for numerous repetitions in each training session. It could be a valuable tool in training novice providers and allow more experienced providers to maintain competence in this low-volume procedure.

Do Social Deprivation and Surgical Volume Influence Outcomes Following Distal Radius Fracture Fixation?

BACKGROUND

Distal radius fractures account for nearly 25% of fractures in adults, with a trend toward operative fixation. The objective of this study was to assess the relationship between surgeon and hospital volume with complications following distal radius fixation.

METHODS

A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009 to 2015. Outpatient claims were identified for distal radius fractures and surgery. The facility and surgeon's identifier were used to calculate annual procedure volume. The risk for infection, carpal tunnel surgery, and revision/hardware removal was analyzed, and Social Deprivation Index (SDI) was linked to each patient. Patient demographics and rate of complications were compared across hospital and physician volume.

RESULTS

A total of 14 748 patients were included, finding Federal and self-pay insurance associated with low-volume (LV) facility care and private insurance with high-volume (HV) facilities. The SDI for patients treated by LV surgeons and hospitals was significantly higher compared with HV providers. Low-volume facilities and surgeons had a higher 3-month risk of infection requiring reoperation. High-volume facilities were less likely to treat Hispanic patients, those with comorbidities, higher SDI, and with Federal or self-pay insurance.

CONCLUSIONS

Patients treated by LV surgeons and facilities had a higher risk of infection requiring surgery within 3 months than those treated by HV providers. Low-volume facilities were more likely to treat patients who were Hispanic, Federally insured, and with comorbidities and higher SDI than HV facilities, increasing their risk for disadvantaged care.

LEVEL OF EVIDENCE

Level III.

Development of Prediction Model for 1-year Mortality after Hip Fracture Surgery

Purpose

Hip fractures are associated with increased mortality. The identification of risk factors of mortality could improve patient care. The aim of the study was to identify risk factors of mortality after surgery for a hip fracture and construct a mortality model.

Materials and Methods

A cohort study was conducted on patients with hip fractures at two institutions. Five hundred and ninety-seven patients with hip fractures that were treated in the tertiary hospital, and another 147 patients that were treated in a secondary hospital. The perioperative data were collected from medical charts and interviews. Functional Assessment Measure score, Short Form-12 and mortality were recorded at 12 months. Patients and surgery variables that were associated with increased mortality were used to develop a mortality model.

Results

Mortality for the whole cohort was 19.4% at one year. From the variables tested only age >80 years, American Society of Anesthesiologists category, time to surgery (>48 hours), Charlson comorbidity index, sex, use of anti-coagulants, and body mass index <25 kg/m2 were associated with increased mortality and used to construct the mortality model. The area under the curve for the prediction model was 0.814. Functional outcome at one year was similar to preoperative status, even though their level of physical function dropped after the hip surgery and slowly recovered.

Conclusion

The mortality prediction model that was developed in this study calculates the risk of death at one year for patients with hip fractures, is simple, and could detect high risk patients that need special management.

Unipolar Hemiarthroplasty, Bipolar Hemiarthroplasty, or Total Hip Arthroplasty for Hip Fracture in Older Individuals

BACKGROUND

Practice patterns regarding the use of unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty (THA) for femoral neck fractures in older patients vary widely. This is due in part to limited data stipulating the specific circumstances under which each form of arthroplasty provides the most predictable outcome. The purpose of this study was to investigate the patient characteristics for which unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA might be preferable due to a lower risk of all-cause revision.

METHODS

A U.S. health-care system's hip fracture registry was used to identify patients ≥60 years old who underwent unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA for hip fracture from 2009 through 2021. Unipolar and bipolar hemiarthroplasty were compared with THA within patient subgroups defined by age (60 to 79 versus ≥80 years) and American Society of Anesthesiologists (ASA) classification (I or II versus III); patients with an ASA classification of IV or higher were excluded. Multivariable Cox proportional hazard regression analysis was used to evaluate all-cause revision risk while adjusting for confounders, with mortality considered as a competing risk.

RESULTS

There were 14,277 patients in the final sample (median age, 82 years; 70% female; 80% White; 69% with an ASA classification of III; median follow-up, 2.7 years), and the procedures included 7,587 unipolar hemiarthroplasties, 5,479 bipolar hemiarthroplasties, and 1,211 THAs. In the multivariable analysis of all patients, both unipolar (hazard ratio [HR] = 2.15, 95% confidence interval [CI] = 1.48 to 3.12; p < 0.001) and bipolar (HR = 1.92, 95% CI = 1.31 to 2.80; p < 0.001) hemiarthroplasty had higher revision risks than THA. In the age-stratified multivariable analysis of patients aged 60 to 79 years, both unipolar (HR = 2.17, 95% CI = 1.42 to 3.34; p = 0.004) and bipolar (HR = 1.69, 95% CI = 1.08 to 2.65; p = 0.022) hemiarthroplasty also had higher revision risks than THA. In the ASA-stratified multivariable analysis, patients with an ASA classification of I or II had a higher revision risk after either unipolar (HR = 3.52, 95% CI = 1.87 to 6.64; p < 0.001) or bipolar (HR = 2.31, 95% CI = 1.19 to 4.49; p = 0.013) hemiarthroplasty than after THA. No difference in revision risk between either of the hemiarthroplasties and THA was observed among patients with an age of ≥80 years or those with an ASA classification of III.

CONCLUSIONS

In this study of hip fractures in older patients, THA was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients who were 60 to 79 years old and those who had an ASA classification of I or II.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Excess mortality in elderly hip fracture patients: An Indian experience

PURPOSE

Hip fractures in elderly have a high mortality. However, there is limited literature on the excess mortality seen in hip fractures compared to the normal population. The purpose of this study was to compare the mortality of hip fractures with that of age and gender matched Indian population.

METHODS

There are 283 patients with hip fractures aged above 50 years admitted at single centre prospectively enrolled in this study. Patients were followed up for 1 year and the follow-up record was available for 279 patients. Mortality was assessed during the follow-up from chart review and/or by telephonic interview. One-year mortality of Indian population was obtained from public databases. Standardized mortality ratio (SMR) (observed mortality divided by expected mortality) was calculated. Kaplan-Meir analysis was used.

RESULTS

The overall 1-year mortality was 19.0% (53/279). Mortality increased with age (p < 0.001) and the highest mortality was seen in those above 80 years (aged 50 - 59 years: 5.0%, aged 60 - 69 years: 19.7%, aged 70 - 79 years: 15.8%, and aged over 80 years: 33.3%). Expected mortality of Indian population of similar age and gender profile was 3.7%, giving a SMR of 5.5. SMR for different age quintiles were: 3.9 (aged 50 - 59 years), 6.6 (aged 60 - 69 years), 2.2 (aged 70 - 79 years); and 2.0 (aged over 80 years). SMR in males and females were 5.7 and 5.3, respectively.

CONCLUSIONS

Indian patients sustaining hip fractures were about 5 times more likely to die than the general population. Although mortality rates increased with age, the highest excess mortality was seen in relatively younger patients. Hip fracture mortality was even higher than that of myocardial infarction, breast cancer, and cervical cancer.

Higher Surgeon Volume is Associated With a Lower Rate of Subsequent Revision Procedures After Total Shoulder Arthroplasty: A National Analysis

BACKGROUND

Studies assessing the relationship between surgeon volume and outcomes have shown mixed results, depending on the specific procedure analyzed. This volume relationship has not been well studied in patients undergoing total shoulder arthroplasty (TSA), but it should be, because this procedure is common, expensive, and potentially morbid.

QUESTIONS/PURPOSES

We performed this study to assess the association between increasing surgeon volume and decreasing rate of revision at 2 years for (1) anatomic TSA (aTSA) and (2) reverse TSA (rTSA) in the United States.

METHODS

In this retrospective study, we used Centers for Medicare and Medicaid Services (CMS) fee-for-service inpatient and outpatient data from 2015 to 2021 to study the association between annual surgeon aTSA and rTSA volume and 2-year revision shoulder procedures after the initial surgery. The CMS database was chosen for this study because it is a national sample and can be used to follow patients over time. We included patients with Diagnosis-related Group code 483 and Current Procedural Terminology code 23472 for TSA (these codes include both aTSA and rTSA). We used International Classification of Diseases, Tenth Revision, procedural codes. Patients who underwent shoulder arthroplasty for fracture (10% [17,524 of 173,242]) were excluded. We studied the variables associated with the subsequent procedure rate through a generalized linear model, controlling for confounders such as patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, hospital size and teaching status, assuming a binomial distribution with the dependent variable being whether an episode had at least one subsequent procedure within 2 years. The regression was fitted with standard errors clustered at the hospital level, combining all TSAs and within the aTSA and rTSA groups, respectively. Hospital and surgeon yearly volumes were calculated by including all TSAs, primary procedure and subsequent, during the study period. Other hospital-level and surgeon-level characteristics were obtained through public files from the CMS. The CMS Hierarchical Condition Category risk score was controlled because it is a measure reflecting the expected future health costs for each patient based on the patient's demographics and chronic illnesses. We then converted regression coefficients to the percentage change in the odds of having a subsequent procedure.

RESULTS

After controlling for confounding variables including patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, and hospital size and teaching status, we found that an annual surgeon volume of ≥ 10 aTSAs was associated with a 27% decreased odds of revision within 2 years (95% confidence interval 13% to 39%; p < 0.001), while surgeon volume of ≥ 29 aTSAs was associated with a 33% decreased odds of revision within 2 years (95% CI 18% to 45%; p < 0.001) compared with a volume of fewer than four aTSAs per year. Annual surgeon volume of ≥ 29 rTSAs was associated with a 26% decreased odds of revision within 2 years (95% CI 9% to 39%; p < 0.001).

CONCLUSION

Surgeons should consider modalities such as virtual planning software, templating, or enhanced surgeon training to aid lower-volume surgeons who perform aTSA and rTSA. More research is needed to assess the value of these modalities and their relationship with the rates of subsequent revision.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures

OBJECTIVES

The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation.

METHODS

Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities.

RESULTS

Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism.

CONCLUSION

There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

Risk of Aseptic Revision and Periprosthetic Fracture Following Bipolar Versus Unipolar Hemiarthroplasty

Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States.

Methods

We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition.

Results

The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16).

Conclusions

In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prolonged Opioid Usage Following Hip Fracture Surgery in Opioid-Naïve Older Patients

BACKGROUND

While the risk of long-term dependence following the opioid treatment of musculoskeletal injury is often studied in younger populations, studies in older patients have centered on short-term risks such as oversedation and delirium. This study investigated prolonged opioid usage after hip fracture in older individuals, focusing on prevalence, risk factors, and changes over time.

METHODS

In this retrospective cohort study of 47,309 opioid-naïve patients aged ≥ 60 years who underwent hip fracture surgery (2009 to 2020), outpatient opioid use was evaluated in 3 postoperative time periods: P1 (day 0 to 30 postsurgery); P2 (day 31 to 90); and P3 (day 91 to 180). The primary outcome was prolonged outpatient opioid use, defined as having one or more opioid prescriptions dispensed in all 3 time periods.

RESULTS

The incidence of prolonged opioid usage among patients surviving to P3 was 6.3% (2,834 of 44,850). Initial prescription quantities decreased over time, as did the risk of prolonged opioid usage (from 8.0% in 2009 to 3.9% in 2019). In the multivariable analyses, risk factors for prolonged opioid usage included younger age, women, current/former smoking, fracture fixation (as compared to hemiarthroplasty), and anxiety. Prolonged opioid usage was less common among patients who were Asian or had a history of dementia.

CONCLUSIONS

While prior research on the hazards of opioids in the elderly has focused on short-term risks such as oversedation and delirium, these findings suggest that prolonged opioid usage may be a risk for this older population as well. As initial prescription amounts have decreased, declines in prolonged opioid medication usage have also been observed.

Mortality following hip fracture: Trends and geographical variations over the last SIXTY years

INTRODUCTION

The management of hip fractures has advanced on all aspects from prevention pre-operatively, specialised hip fracture units, early operative intervention and rehabilitation. This is in line with the appropriate recognition over the past years of an important presentation with significant mortality and socioeconomic consequences of ever increasing incidence in an aging population. It is therefore imperative to continue to gather data on the incidence and trends of hip fractures to guide future management planning of this important presentation.

METHODS

A review of all articles published on the outcome after hip fracture over a twenty year period (1999-2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 - 1998) and attempts to present trends and geographical variations over sixty years.

RESULTS

The mean age of patients sustaining hip fractures continues to be steadily increasing at approximately just over 1 year of age for every 5-year time period. The mean age of patients sustaining hip fractures increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from an overall mean of 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% (2010s). There is a decreasing trend in the proportion of intracapsular fractures from 54% (1970s) to 49% (2000s) and 48% (2010s).

CONCLUSION

Our study indicates that significant progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical urgency all playing a role in the improvements in mean age of hip fracture incidence and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally with results now being published from more widespread institutions indicating appropriate increased attention and commitment to an ever-increasing presentation.

Navigated intramedullary nailing for patients with intertrochanteric hip fractures is cost-effective at high-volume hospitals in mainland China: A markov decision analysis

Objective

Previous studies have reported that navigation systems can improve clinical outcomes of intramedullary nailing (IMN) for patients with intertrochanteric fractures. However, information is lacking regarding the relationship between the costs of navigated systems and clinical outcomes. The present research aimed to evaluate the cost-effectiveness of navigated IMN as compared with traditional freehand IMN for patients with intertrochanteric fractures.

Methods

A Markov decision model with a 5-year time horizon was constructed to investigate the costs, clinical outcomes and incremental cost-effectiveness ratio (ICER) of navigated IMN for a 70-year-old patient with an intertrochanteric fracture in mainland China. The costs [Chinese Yuan (¥)], health utilities (quality-adjusted life-years, QALYs) and transition probabilities were obtained from published studies. The willingness-to-pay threshold for ICER was set at ¥1,40,000/QALY following the Chinese gross domestic product in 2020. Three institutional surgical volumes were used to determine the average navigation-related costs per patient: low volume (100 cases), medium volume (200 cases) and high volume (300 cases).

Results

Institutes at which 300, 200 and 100 cases of navigated IMN were performed per year showed an ICER of ¥43,149/QALY, ¥76,132.5/QALY and ¥1,75,083/QALY, respectively. Navigated IMN would achieve cost-effectiveness at institutes with an annual volume of more than 125 cases.

Conclusions

Our analysis demonstrated that the navigated IMN could be cost-effective for patients with inter-trochanteric fracture as compared to traditional freehand IMN. However, the cost-effectiveness was more likely to be achieved at institutes with a higher surgical volume.

Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care

Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments.

INTRODUCTION

An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation.

METHODS

We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome.

RESULTS

There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk.

CONCLUSIONS

There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.

Surgeon case volume and the risk of complications following surgeries of displaced intra-articular calcaneal fracture

PURPOSE

This study aimed to address the relationship between surgeon volume and the risk of complications following surgeries of displaced intra-articular calcaneal fractures (DIACFs).

METHODS

We retrospectively reviewed the medical records and the follow-up registers for patients who underwent open reduction and internal fixation with plate/screws in our center between January 2015 and June 2020. Surgeon volume was defined as the number of surgically treated calcaneal fractures within the past 12 months, and was dichotomized on basis of the optimal cut-off value. The outcome measure was the documented overall complications within 1 year after surgery. Four logistics regression models were constructed to examine the potential relationship between surgeon volume and complications.

RESULTS

Among 585 patients, 49 had documented complications, representing an overall rate of 8.4%. The overall complication rate was 20.0% (22/111) in patients operated on by the low-volume surgeons and 5.7% (27/474) by the high-volume surgeons, with a significant difference (p < 0.001). The 4 multivariate analyses showed steady and robust inverse volume-complication relationship, with OR ranging from 3.8 to 4.4. The restricted cubic splines adjusted for total covariates showed the non-linear fitting "L-shape" or "reverse J-shape" curve (p = 0.041), and the OR was reduced until 10 cases, beyond which the curve leveled.

CONCLUSIONS

Our findings reflected the important role of maintaining necessary operative cases, potentially informing optimized surgical care management.

Is Radiographic Osteoporotic Hip Morphology A Predictor For High Mortality Following Intertrochanteric Femur Fractures?: Osteoporotic Hip Morphology & Mortality

INTRODUCTION

Factors related to mortality after intertrochanteric femur fractures (ITFF) have been investigated intensively in the literature except for radiographic osteoporotic hip morphology. The aim of this study is to investigate the relationship between mortality and radiographic osteoporotic hip morphology of patients with ITFF.

PATIENTS AND METHODS

Patients who underwent surgery between the dates of January 2012 and June 2018 due to ITFF were retrospectively reviewed. Osteoporotic status of the proximal femur was determined based on Singh Index grading and Dorr classification systems on preoperative anteroposterior pelvis radiographs of contralateral hips. The mortality rates of the patients were measured at 1st, 3rd, 6th, and 12th months. For controlling the confounders, multiple regression analysis was performed.

RESULTS

A total of 321 consecutive ITFFs were included in the study. The mean age of the patients was 81.5 ± 6.6 years. All patients were treated with osteosynthesis utilizing a cephalomedullary nail. The overall mortality rates at 1st, 3rd, 6th, and 12th months were 7.2%, 13.4%, 16.2%, 22.7%, respectively. There was 2.196 (1.140 - 4.229) folds increase in the mortality rate of patients with the Dorr type C femurs at 6th month (p=0.019). However, Singh index grade was not significantly associated with mortality.

CONCLUSION

Patients with Dorr type C femur seem to have 2.1 times increased mortality at 6th months following ITFFs. A simple anteroposterior pelvis radiograph obtained during the initial evaluation of the patients may be used to estimate the mortality rate after ITFF.

Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1 year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.

A multi-institutional prospective observational study to evaluate fascia iliaca compartment block (FICB) for preventing delirium in adults with hip fracture

Objectives

Until recently, systemic opioids have been standard care for acute pain management of geriatric hip fracture; however, opioids increase risk for delirium. Fascia Iliaca compartment blocks (FICB) may be favored to systemic analgesia for reducing delirium, but this has not been well demonstrated. We evaluated the efficacy of adjunctive FICB versus systemic analgesia on delirium incidence, opioid consumption, and pain scores.

Methods

This prospective, observational cohort study was performed in patients (55-90 years) with traumatic hip fracture admitted to five trauma centers within 12 hours of injury, enrolled between January 2019 and November 2020. The primary end point was development of delirium, defined by the Confusion Assessment Method tool, from arrival through 48 hours postoperatively, and analyzed with multivariate Firth logistic regression. Secondary end points were analyzed with analysis of covariance models and included preoperative and postoperative oral morphine equivalents and pain numeric rating scale scores.

Results

There were 517 patients enrolled, 381 (74%) received FICB and 136 (26%) did not. Delirium incidence was 5.4% (n=28) and was similar for patients receiving FICB versus no FICB (FICB, 5.8% and no FICB, 4.4%; adjusted OR: 1.2 (95% CI 0.5 to 3.0), p=0.65). Opioid requirements were similar for patients receiving FICB and no FICB, preoperatively (p=0.75) and postoperatively (p=0.51). Pain scores were significantly lower with FICB than no FICB, preoperatively (4.2 vs 5.1, p=0.002) and postoperatively (2.9 vs 3.5, p=0.04).

Conclusions

FICB demonstrated significant benefit on self-reported pain but without a concomitant reduction in opioid consumption. Regarding delirium incidence, these findings suggest clinical equipoise and the need for a randomized trial.

Level of evidence

II-prospective, therapeutic.

One-Year Postfracture Mortality Rate in Older Adults With Hip Fractures Relative to Other Lower Extremity Fractures: Retrospective Cohort Study

BACKGROUND

Hip fracture in older adults is tied to increased mortality risk. Deconvolution of the mortality risk specific to hip fracture from that of various other fracture types has not been performed in recent hip fracture studies but is critical to determining current unmet needs for therapeutic intervention.

OBJECTIVE

This study examined whether hip fracture increases the 1-year postfracture mortality rate relative to several other fracture types and determined whether dementia or type 2 diabetes (T2D) exacerbates postfracture mortality risk.

METHODS

TriNetX Diamond Network data were used to identify patients with a single event of fracture of the hip, the upper humerus, or several regions near and distal to the hip occurring from 60 to 89 years of age from 2010 to 2019. Propensity score matching, Kaplan-Meier, and hazard ratio analyses were performed for all fracture groupings relative to hip fracture. One-year postfracture mortality rates in elderly populations with dementia or T2D were established.

RESULTS

One-year mortality rates following hip fracture consistently exceeded all other lower extremity fracture groupings as well as the upper humerus. Survival probabilities were significantly lower in the hip fracture groups, even after propensity score matching was performed on cohorts for a variety of broad categories of characteristics. Dementia in younger elderly cohorts acted synergistically with hip fracture to exacerbate the 1-year mortality risk. T2D did not exacerbate the 1-year mortality risk beyond mere additive effects.

CONCLUSIONS

Elderly patients with hip fracture have a significantly decreased survival probability. Greatly increased 1-year mortality rates following hip fracture may arise from differences in bone quality, bone density, trauma, concomitant fractures, postfracture treatments or diagnoses, restoration of prefracture mobility, or a combination thereof. The synergistic effect of dementia may suggest detrimental mechanistic or behavioral combinations for these 2 comorbidities. Renewed efforts should focus on modulating the mechanisms behind this heightened mortality risk, with particular attention to mobility and comorbid dementia.

Association Between the Femoral Stem Design Type and the Risk of Aseptic Revision After Hemiarthroplasty

INTRODUCTION

Although noncemented hemiarthroplasty has been associated with a higher risk of revision surgery as compared with cemented fixation, it remains uncertain whether this increased risk applies to all noncemented stem design types or only a subset. The purpose of this study was to assess the risk of aseptic revision associated with three common types of noncemented stem designs as compared with cemented fixation in the hemiarthroplasty treatment of femoral neck fractures in the elderly patients.

METHODS

This was a retrospective cohort study of patients aged 60 years and older who sustained a hip fracture and underwent hemiarthroplasty between 2009 and 2018 at one of 35 hospitals owned by a large US health maintenance organization. Hemiarthroplasty fixation was categorized as cemented or noncemented, with the noncemented stems further classified as single wedge without collar, fit and fill without collar, or fit and fill with collar. The primary outcome was aseptic revision, and the median follow-up time was 4.8 years.

RESULTS

Of 12,071 patients who underwent hemiarthroplasty during the study period (average age 82.0 ± 8.4 years, 67.9% women), 807 (6.7%) received a single-wedge stem without collar, 2,124 (17.6%) received a fit-and-fill stem without collar, 2,453 (20.3%) received a fit-and-fill stem with collar, and 6,687 (55.4%) received a cemented stem. Compared with cemented fixation, all the noncemented stem design types were associated with a markedly higher risk of aseptic revision in the multivariable analysis, including single wedge without collar (hazard ratio [HR] 2.00, 95% confidence interval [CI], 1.38 to 2.89, P < 0.001), fit and fill without collar (HR 1.52, 95% CI, 1.14 to 2.04, P = 0.005), and fit and fill with collar (HR 2.11, 95% CI, 1.63 to 2.72, P < 0.001).

CONCLUSION

In the hemiarthroplasty treatment of elderly patients with hip fracture, all routinely used noncemented stem design types were associated with a higher risk of aseptic revision as compared with cemented fixation.

The case for decreased surgeon-reported complications due to surgical volume and fellowship status in the treatment of geriatric hip fracture: An analysis of the ABOS database

Introduction

American orthopaedists are increasingly seeking fellowship sub-specialization. One proposed benefit of fellowship training is decrease in complications, however, few studies have investigated the rates of medical and surgical complications for hip fracture patients between orthopedists from different fellowship backgrounds. This study aims to investigate the effect of fellowship training and case volume on medical and surgical outcomes of patient following hip fracture surgical intervention.

Methods

1999–2016 American Board of Orthopedic Surgery (ABOS) Part II Examination Case List data were used to assess patients treated by trauma or adult reconstruction fellowship-trained orthopedists versus all-other orthopaedists. Rates of surgeon-reported medical and surgical adverse events were compared between the three surgeon cohorts. Using binary multivariate logistic regression to control of demographic factors, independent factors were evaluated for their effect on surgical complications.

Results

Data from 73,427 patients were assessed. An increasing number of hip fractures are being treated by trauma fellowship trained surgeons (9.43% in 1999–2004 to 60.92% in 2011–2016). In multivariate analysis, there was no significant difference in type of fellowship, however, surgeons with increased case volume saw significantly decreased odds of complications (16–30 cases: OR = 0.91; 95% CI: 0.85–0.97; p = 0.003; 31+ cases: OR = 0.68; 95% CI: 0.61–0.76; p<0.001). Femoral neck hip fractures were associated with increased odds of surgical complications.

Discussion

Despite minor differences in incidence of surgical complications between different fellowship trained orthopaedists, there is no major difference in overall risk of surgical complications for hip fracture patients based on fellowship status of early orthopaedic surgeons. However, case volume does significantly decrease the risk of surgical complications among these patients and may stand as a proxy for fellowship training. Fellows required to take hip fracture call as part of their training regardless of fellowship status exhibited decreased complication risk for hip fracture patients, thus highlighting the importance of additional training.

Age and clinical outcomes after hip fracture surgery: do octogenarian, nonagenarian and centenarian classifications matter?

BACKGROUND

older patients with hip fractures are arbitrarily classified as octogenarians, nonagenarians and centenarians. We have designed this study to quantify in-hospital mortality and complications among each of these groups. We hypothesised that the associations between age and in-hospital mortality and complications are continuously increasing, and that these risks increase rapidly when patients reach a certain age.

METHODS

this research is a retrospective cohort study using nationwide database between 2010 and 2018. Patients undergoing hip fracture surgery, and aged 60 or older, were included. The associations between patient age, in-hospital mortality and complications were visualised using the restricted cubic spline models, and were analysed employing multivariable regression models. Then, octogenarians, nonagenarians and centenarians were compared.

RESULTS

among a total of 565,950 patients, 48.7% (n = 275,775) were octogenarians, 23.0% (n = 129,937) were nonagenarians and 0.7% (n = 4,093) were centenarians. The models presented three types of association between age, in-hospital mortality and complications: (i) a continuous increase (mortality and respiratory complications); (ii) a mild increase followed by a steep rise (intensive care unit admission, heart failure, renal failure and surgical site hematoma) and (iii) a steep increase followed by a limited change (coronary heart disease, stroke and pulmonary embolisms).

CONCLUSION

we identified three types of association between age and clinical outcomes. Patients aged 85-90 may constitute the upper threshold for age categorisations, because the risk of in-hospital complications changed dramatically at that stage. This information can improve clinical awareness of various complications and support collective decision-making.

Relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation of displaced intra-articular calcaneal fracture

It is well established that the postoperative results were affected by the surgeon volume in a variety of elective and emergent orthopaedic surgeries; however, by far, no evidences have been available as for surgically treated displaced intra-articular calcaneal fractures (DIACFs). We aimed at investigating the relationship between surgeon volume and deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of DIACFs. This was a further analysis of prospectively collected data from a validated database. Patients with DIACFs stabilised by ORIF between 2016 and 2019 were identified. Surgeon volume was defined as the number of surgically treated calcaneal fractures within one calendar year and was dichotomised based on the optimal cut-off value. The outcome measure was DSSI within 1 year postoperatively. Multivariate logistics regression analyses were performed to examine the relationship, adjusting for confounders. Among 883 patients, 19 (2.2%) were found to have a DSSI. The DSSI incidence was 6.5% in surgeons with a low volume (<6/year), 5.5 times as that in those with a high volume (≥6/year) (incidence rate, 1.2%; P < 0.001). The multivariate analyses showed a low volume <6/year was associated with a 5.8-fold increased risk of DSSI (95% confidence interval, 2.2-16.5, P < 0.001). This value slightly increased after multiple sensitivity analyses, with statistical significances still unchanged (OR range, 6.6-6.9; P ≤ 0.001). The inverse relationship indicates a need for at least six cases/year for a surgeon to substantially reduce the DSSIs following the ORIF of DIACFs.

Subcuticular Barbed Suture and Skin Glue Wound Closure Decreases Reoperation and Length of Stay in Geriatric Hip Fractures When Compared With Staples

INTRODUCTION

Patients with geriatric hip fracture are notoriously frail and at risk for complications. Persistent postoperative wound drainage can lead to prolonged hospital stay, increased risk for infection, and need for revision surgery. The purpose of this study was to determine the effect of wound closure technique, barbed monofilament subcuticular suture and skin glue versus staples on rates of intervention for wound drainage and length of hospital stay after geriatric hip fracture fixation.

METHODS

A retrospective review of isolated hip fractures in patients older than 60 years at a single institution over a 3-year period was done. Hip fractures included femoral neck, intertrochanteric, and subtrochanteric femur fractures treated with internal fixation or arthroplasty. Skin closure technique, at the discretion of the operating surgeon, included either barbed subcuticular monofilament suture and skin glue or staples. Charts and radiographs were reviewed to determine patient characteristics, Charlson Comorbidity Index, type of wound closure, length of stay, and interventions for persistent wound drainage.

RESULTS

There were 175 patients in the barbed suture and skin glue group and 211 patients in the staples group. The barbed suture group had an average postsurgical length of stay of 5.0 days which was significantly lower than the staples group (7.0 days, P < 0.00001). In the staples group, 17 patients (8%) required incisional negative pressure wound therapy due to wound drainage with five patients (2.4%) returning to the operating room secondary to persistent wound drainage. No patients were observed in the barbed suture group that required intervention for wound drainage.

DISCUSSION

Barbed suture and skin glue closure is associated with markedly shorter hospital stay and fewer interventions for wound drainage when compared with staples after surgical treatment of geriatric hip fractures.

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BACKGROUND

For displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF.

METHODS

A nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge.

RESULTS

By visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients' propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively).

CONCLUSION

Our research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.

Surgeon volume and the risk of deep surgical site infection following open reduction and internal fixation of closed tibial plateau fracture

BACKGROUND

Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture.

METHODS

This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12 months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within one year post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups.

RESULTS

Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14 days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5).

CONCLUSION

The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.

A Case-Control Study of Hip Fracture Surgery Timing and Mortality at an Academic Hospital: Day Surgery May Be Safer than Night Surgery

Time from hospital admission to operative intervention has been consistently demonstrated to have a significant impact on mortality. Nonetheless, the relationship between operative start time (day versus night) and associated mortality has not been thoroughly investigated. Methods: All patients who underwent hip fracture surgery at a single academic institution were retrospectively analyzed. Operative start times were dichotomized: (1) day operation—7 a.m. to 4 p.m.; (2) night operation—4 p.m. to 7 a.m. Outcomes between the two groups were evaluated. Results: Overall, 170 patients were included in this study. The average admission to operating room (OR) time was 26.0 ± 18.0 h, and 71.2% of cases were performed as a day operation. The overall 90-day mortality rate was 7.1% and was significantly higher for night operations (18.4% vs. 2.5%; p = 0.001). Following multivariable logistic regression analysis, only night operations were independently associated with 90-day mortality (aOR 8.91, 95% confidence interval 2.19–33.22; p = 0.002). Moreover, these patients were significantly more likely to return to the hospital within 50 days (34.7% vs. 19.0%; p = 0.029) and experience mortality prior to discharge (8.2% vs. 0.8%; p = 0.025). Notably, admission to OR time was not associated with in-hospital mortality (29.22 vs. 25.90 h; p = 0.685). Hip fracture surgery during daytime operative hours may minimize mortalities.

Impact of centre volume, surgeon volume, surgeon experience and geographic location on reoperation after intramedullary nailing of tibial shaft fractures

Background:

Tibial shaft fractures are the most common long-bone injury, with a reported annual incidence of more than 75 000 in the United States. This study aimed to determine whether patients with tibial fractures managed with intramedullary nails experience a lower rate of reoperation if treated at higher-volume hospitals, or by higher-volume or more experienced surgeons.

Methods:

The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) was a multicentre randomized clinical trial comparing reamed and nonreamed intramedullary nailing on rates of reoperation to promote fracture union, treat infection or preserve the limb in patients with open and closed fractures of the tibial shaft. Using data from SPRINT, we quantified centre and surgeon volumes into quintiles. We performed analyses adjusted for type of fracture (open v. closed), type of injury (isolated v. multitrauma), gender and age for the primary outcome of reoperation using multivariable logistic regression.

Results:

There were no significant differences in the odds of reoperation between high- and low-volume centres (p = 0.9). Overall, surgeon volume significantly affected the odds of reoperation (p = 0.03). The odds of reoperation among patients treated by moderate-volume surgeons were 50% less than those among patients treated by very-low-volume surgeons (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.28–0.88), and the odds of reoperation among patients treated by high-volume surgeons were 47% less than those among patients treated by very-low-volume surgeons (OR 0.53, 95% CI 0.30–0.93).

Conclusion:

There appears to be no significant additional patient benefit in treatment by a higher-volume centre for intramedullary fixation of tibial shaft fractures. Additional research on the effects of surgical and clinical site volume in tibial shaft fracture management is needed to confirm this finding. The odds of reoperation were higher in patients treated by very-low-volume surgeons; this finding may be used to optimize the results of tibial shaft fracture management.

Clinical trial registration:

ClinicalTrials.gov, NCT00038129

Minimizing Nonessential Follow-up for Hip Fracture Patients

Hip fractures pose a significant burden to patients and care providers. The optimal protocol for postoperative care across all surgically treated hip fracture patients is unknown. The purpose of this study was to investigate the effect that routine follow-up had on changing the clinical course.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

Mortality incidence and its determinants after fragility hip fractures: a prospective cohort study from an Egyptian level one trauma center

Background

Fragility hip fracture is a common condition with serious consequences. Most outcomes data come from Western and Asian populations. There are few data from African and Middle Eastern countries.

Objective

The primary objective was to describe mortality rates after fragility hip fracture in a Level-1 trauma centre in Egypt. The secondary objective was to study the causes of re-admissions, complications, and mortality.

Methods

A prospective cohort study of 301 patients, aged > 65 years, with fragility hip fractures. Data collected included sociodemographic, co-morbidities, timing of admission, and intraoperative,ostoperative, and post-discharge data as mortality, complications, hospital stay, reoperation, and re-admission. Cox regression analysis was conducted to investigate factors associated with 1-year mortality.

Results

In-hospital mortality was 8.3% (25 patients) which increased to 52.8% (159 patients) after one year; 58.5% of the deaths occurred in the first 3-months. One-year mortality was independently associated with increasing age, ASA 3–4, cardiac or hepatic co-morbidities, trochanteric fractures, total hospital stay, and postoperative ifection and metal failure.

Conclusion

Our in-hospital mortality rate resembles developed countries reports, reflecting good initial geriatric healthcare. However, our 3- and 12-months mortality rates are unexpectedly high. The implementation of orthogeriatric care after discharge is mandatory to decrease mortality rates.

Hip fractures in Spain: are we on the right track? Statistically significant differences in hip fracture management between Autonomous Communities in Spain

Although medicine is currently protocol-based, there are still differences in the management of the hip fracture in Spain, especially regarding surgical delay, type of anesthesia, early mobilization, and discharge destinations. This data will be of great value to assist stakeholders in formulating health policies.

PURPOSE

Analysis of demographic, clinical, surgical, and functional data of the Spanish National Hip Fracture National Registry (RNFC), during admission and at 1-month follow-up, by Autonomous Communities (ACs).

METHODS

Cross-sectional analysis in the framework of a RNFC cohort, from January 2017 to May 2018, including 15 ACs from Spain, with 1 month of follow-up. Sociodemographic, clinical, surgical, and outcome variables were analyzed.

RESULTS

In total, 13,839 patients were analyzed. There were significant differences (p <0.001) in median surgical delay and percentage of patients operated in less than 48 h. Mean surgical delay was 70.75 h, with a 12-h difference between the Communities of Madrid (71.22) and Catalonia (59.65). Only 43% of patients had less than 48-h delay. Overall, most patients received regional anesthesia (91.9%); however, there was a significant difference between ACs (p = 0.0001). There were also differences in inpatient stay, early mobilization, discharge destination, and mortality (p <0.001). Mortality 30 days after surgery was 7.8%, and highest in the Basque Country (12.5%).

CONCLUSIONS

The registry showed homogeneity among ACs regarding sociodemographic variables, fracture type, surgical treatment, ASA risk, and co-management with a geriatrician or an integrated internist. There were significant differences in hip fracture management between ACs in Spain, especially regarding surgical delay, type of anesthesia, early mobilization, and discharge destinations.

Low Surgeon and Hospital Volume Increase Risk of Early Conversion to Total Knee Arthroplasty After Tibial Plateau Fixation

BACKGROUND

Some orthopaedic procedures exhibit volume-outcome relationships that suggest benefits associated with a triage and treatment by higher volume surgeons and hospitals. The purpose of this study was to determine whether this association is present for open reduction internal fixation (ORIF) of tibial plateau fractures regarding the outcome of conversion to total knee arthroplasty (TKA).

METHODS

The Florida State Inpatient Database was queried to identify patients who underwent ORIF of a tibial plateau fracture between 2006 and 2009. The annual volumes of surgeons and hospitals were determined. The outcome of interest was any subsequent hospitalization for TKA within 5 years. Comparing the rates of this outcome, cut points were established to define high and low volume. Survival analysis, including Cox proportional hazards modeling, was used to estimate the effect of volume on rates of TKA while controlling for patient factors and injury characteristics.

RESULTS

In this cohort of 3,921 patients, 172 patients (4.4%) underwent TKA within 5 years of ORIF of the tibial plateau. This included 5.0% of patients treated by low-volume surgeons versus 2.1% treated by high-volume surgeons and 4.8% treated at low-volume hospitals versus 2.0% treated at high-volume hospitals. High-volume surgeons and hospitals were defined by annual volumes greater than or equal to 7 and 29, respectively. After adjustment, treatment at a low-volume hospital was associated with a larger hazard of conversion to TKA (hazard ratio = 2.05; 95% confidence interval = 1.11 to 3.80). Treatment by a low-volume surgeon was also associated with a larger hazard of conversion to TKA (hazard ratio = 2.17; 95% confidence interval = 1.31 to 3.59).

DISCUSSION

High-volume treatment of tibial plateau fractures is associated with a lower rate of conversion to TKA, suggesting that the regionalization of care for these injuries may improve outcomes.

LEVEL OF EVIDENCE

Level III.

Survival After Hip Fracture: A Comparative Analysis Between a Private and a Public Health Center in Chile

Purpose

The purpose of the study is to compare the survival after hip fracture in patients older than 50 years after hip fracture between a private and a public health center in Chile. We hypothesize that treatment at a private health center (PRH) may be associated with lower one-year mortality and longer median survival time after hip fracture (adjusted by gender and age) compared to a public health center (PLH).

Methods

PRH and PLH patients who were coded with a diagnosis of hip fracture were included in this study. PRH patients were included between 2002 to 2018, and PLH patients were included from 2012 to 2018. One-year mortality was estimated by logistic regression; meanwhile, median survival time was estimated by exponential regression. A survival analysis study was designed and approved by our institutional ethics review board.

Results

A total of 2130 patients were included in the PLH cohort, and a total of 1110 patients were included in the PRH. The one-year mean mortality, adjusted by age and gender, was 0.23 (range: 0.21 to 0.25) in the PLH and 0.16 (range: 0.13 to 0.18) in the PRH cohort. The median survival time, adjusted by age and gender, was 4.2 years (range: 4.1 to 4.4) in the PLH and 6.8 years (range: 6.3 to 7.29) in the PRH cohort.

Conclusion

Patients older than 50 years treated in a private health center have a higher median survival time and a lower probability of dying one year after a hip fracture.

Osteoporotic hip fracture mortality and associated factors in Hawai'i

The 30-day mortality of osteoporotic hip fracture patients ≥ 50 years at Hawai'i Pacific Health (2015-2016) was 4.2%. Mortality increased to 17.1% (1 year), 24.5% (2 years), and 30.1% (3 years). Increased age, male sex, higher CCI score, primary insurance status-Medicare/Medicaid, and lower BMI were associated with increased mortality.

PURPOSE

The objective of this study was to evaluate mortality and factors associated with mortality of osteoporotic hip fracture patients at community hospitals within a large healthcare system in Hawai'i.

METHODS

A retrospective chart review was conducted of 428 patients, ≥ 50 years, and hospitalized for a osteoporotic hip fracture from January 2015 to May 2016 within a large healthcare system in Hawai'i. Patient demographics, comorbidities, and treatment were collected from retrospective chart review. We determined the date of death by review of medical records and online public obituary records. We calculated 30-day, 90-day, 1-year, 2-year, and 3-year mortality after discharge for hip fracture admission. Multivariable logistic regression and proportional hazards regression were used to evaluate associations between variables and the mortality of the patients.

RESULTS

The 30-day and 90-day mortality after admission for hip fracture were 4.2% and 8.6%. One-year mortality, 2-year mortality, and 3-year mortality were 17.1%, 24.5%, and 30.1%, respectively. Through proportional hazards regression, older age (hazard ratio (HR) = 1.06, p < 0.001), high comorbidity load (HR = 1.30, p < 0.001), and primary insurance status-Medicare/Medicaid (HR = 3.78, p = 0.021) were associated with increased mortality, while female sex (HR = 0.54, p < 0.001) and higher BMI (HR = 0.94, p = 0.002) were associated with lower mortality.

CONCLUSION

After admission for osteoporotic hip fracture, the 30-day mortality was 4.2%. At 1 year, 2 years, and 3 years, mortality increased to 17.1%, 24.5%, and 30.1%, respectively. Increased age, male sex, higher Charlson comorbidity index score, primary insurance status-Medicare/Medicaid, and lower body mass index were associated with increased mortality.

The association between hospital case volume and in-hospital and one-year mortality after hip fracture surgery

Aims

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

Methods

Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery.

Results

Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001).

Conclusion

Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391.

Survival analysis after hip fracture: higher mortality than the general population and delayed surgery increases the risk at any time

PURPOSE

To estimate survival curves in patients with hip fracture according to gender, age, type of fracture, and waiting time for surgery and to compare them with the life expectancy of the general population. The study hypothesis is that survival after hip fractures is significantly lower than in the general population, especially in cases that underwent delayed surgery, regardless of age and gender.

METHODS

A survival analysis study was designed and approved by our institutional ethics review board. All patients who were coded with a diagnosis of hip fracture from 2002 to 2018 were included in the study. A total of 1176 patients were included, and the median age was 81 years (18-105 years). Kaplan-Meier curves and log-rank tests were performed to compare survival curves between those who underwent surgery on time and those with surgical delays. An exponential multivariate regression model was estimated, and a hazard ratio (HR) was reported for age, gender, and wait time for surgery. A significance of 5% was used, and a confidence interval level of 95% was reported.

RESULTS

The Kaplan-Meier curves for delayed surgery (log-rank, p = 0.00) and the age group (log-rank, p = 0.00) were significantly different. Exponential regression estimated an HR 1.05 (1.05-1.07) for age, HR 1.80 (1.51-2.13) for men, and HR 1.93 (1.61-2.31) for each day of wait for surgery.

CONCLUSIONS

The 2 significant findings of this study are that hip fracture patients over 40 years old have a higher risk of dying at any time compared to the general population and that the waiting time for surgery (a modifiable factor) decreases survival rates at any time.

Arthroplasty Surgeons Do Not Improve Acute Outcomes for Patients With Hip Fracture Relative to Other Subspecialists

As bundled reimbursement models continue to evolve, there is a continued effort to increase the value of care for patients undergoing arthroplasty. The authors sought to evaluate the effect of surgeon specialization (arthroplasty vs non-arthroplasty) on acute outcomes for patients with hip fracture who underwent total hip arthroplasty (THA), in an effort to determine whether the value of care can be improved by surgeons specializing in these procedures. They performed a multicenter retrospective cohort study of patients who had hip fracture and were treated with THA between June 2013 and February 2018 at 2 academic institutions that were involved in bundled reimbursement initiatives. Patients were stratified based on the subspecialty training of the operative surgeon (fellowship-trained adult reconstruction vs other orthopedic sub-specialty), and 90-day readmissions, length of stay, and discharge disposition were compared between groups. A total of 291 patients were included in the final cohort, with 120 (41.2%) undergoing surgery performed by a fellowship-trained adult reconstruction surgeon. No significant difference was found in age, sex, race, or American Society of Anesthesiologists score between the 2 groups. In addition, no significant difference was found in length of stay, discharge to a facility, or 90-day readmissions on univariable or multivariable analysis when adjusted for age, sex, body mass index, and American Society of Anesthesiologists score. This study showed that the acute outcomes used to assess the value of care for patients undergoing THA were not significantly different when the surgery was performed by an adult reconstruction specialist compared with other orthopedic surgeons at 2 high-volume academic centers with perioperative care pathways. Alternative modalities to significantly improve acute postoperative outcomes in a bundled reimbursement model must be investigated. [Orthopedics. 2020;43(5):e442-e446.].

Secular Trends in the Incidence of Hip Fracture Among Nursing Home Residents

A recent study suggested a decline in the incidence of hip fracture among US women between 2002 and 2012, followed by a leveling in the incidence rate from 2013 to 2015. Newly admitted nursing home residents are particularly vulnerable to hip fracture, and it is unclear whether that trend is observed in this high risk group. The purpose of our study was to describe trends in hip fracture rates and postfracture mortality among 2.6 million newly admitted US nursing home residents from 2007 to 2015, and to examine whether these trends could be explained by differences in resident characteristics. Medicare claims data were linked with the Minimum Data Set (MDS), a clinical assessment performed quarterly on all nursing home residents. In each year (2007-2015), we identified newly admitted long-stay (ie, 100 days in the same facility) nursing home residents. Hip fracture was defined using Medicare Part A diagnostic codes. Follow-up time was calculated from the index date until the first event of hospitalized hip fracture, Medicare disenrollment, death, or until 1 year. Poisson regression was used to adjust rates of hip fracture for age and sex. The number of newly admitted nursing home residents ranged from 324,508 in 2007 to 257,350 in 2015. Although mean age remained similar (83 years), residents were more functionally dependent over time. There was a small absolute decrease in the incidence rate of hip fracture between 2007 (3.32/100 person-years) and 2013 (2.82/100 person-years), with an increase again in 2015 (3.03/100 person-years). Adjusting for patient characteristics somewhat attenuated these trends. One-year mortality was high following fracture in all years (42.6% in 2007, 42.1% in 2014). In summary, we observed a recent slight rise in the incidence rates of hip fracture among nursing home residents that was at least partially explained by differences in resident characteristics over time. © 2020 American Society for Bone and Mineral Research.

1-Year Mortality and Surgery Incidence in Older US Adults with Cervical Spine Fracture

BACKGROUND

Traumatic cervical spinal cord injuries (SCIs) can be lethal and are especially dangerous for older adults. Falls from standing and risk factors for a cervical fracture and spinal cord injury increase with age. This study estimates the 1-year mortality for patients with a cervical fracture and resultant SCI and compares the mortality rate with that from an isolated cervical fracture.

METHODS

We performed a retrospective cohort study of U.S. Medicare patients older than 65 years of age. International Classification of Diseases (ICD)-9 codes were used to identify patients with a cervical fracture without SCI and patients with a cervical fracture with SCI between 2007 and 2014. Our primary outcome was 1-year mortality cumulative incidence rate; our secondary outcome was the cumulative incidence rate of surgical intervention. Propensity weighted analysis was performed to balance covariates between the groups.

RESULTS

The SCI cohort had a 1-year mortality of 36.5%, compared with 31.1% in patients with an isolated cervical fracture (risk difference 5.4% (2.9%-7.9%)). Patients with an SCI were also more likely to undergo surgical intervention compared with those without a SCI (23.1% and 10.3%, respectively; risk difference 12.8% (10.8%-14.9%)).

CONCLUSIONS

Using well-adjusted population-level data in older adults, this study estimates the 1-year mortality after SCI in older adults to be 36.5%. The mortality after a cervical fracture with SCI was 5 percentage points higher than in patients without SCI, and this difference is smaller than one might expect, likely representing the frailty of this population and unmeasured covariates.

Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures?

BACKGROUND

This study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers.

METHODS

Hemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining "high-volume" hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable.

RESULTS

In total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes.

CONCLUSION

A clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable.

LEVEL OF EVIDENCE

Prognostic Level III.

Evaluation of the volume-value relationship in hip fracture care using evidence-based thresholds

BACKGROUND

Studies have shown high-volume surgeons and hospitals deliver higher value care. The aims of this study were to establish meaningful thresholds defining high-volume surgeons and hospitals performing hip fracture surgery and to examine the relative market share of hip fracture cases using these surgeon and hospital strata.

METHODS

We performed a retrospective cohort study in a database of 103,935 patients undergoing hip fracture repair. We generated stratum-specific likelihood ratio (SSLR) models of a receiver operating characteristic (ROC) curve using length of stay (LOS) and cost value metrics. Volume thresholds predictive of decreased LOS and costs for surgeons and hospitals were identified.

RESULTS

Analysis of annual surgeon hip fracture volume produced two volume categories for LOS and cost: 0-30 (low) and 31+ (high). Analysis of LOS by annual hospital hip fracture volume produced strata at: 0-59 (low), 60-146 (medium), and 147 or more (high). Analysis of cost by annual hospital volume produced strata at: 0-125 (low) and 126+ (high). LOS and cost both decreased significantly (p < 0.05) in progressively higher volume categories. Low-volume surgeons performed the majority of hip fracture cases, although they were performed at medium- or high-volume centres.

CONCLUSIONS

This study demonstrates a direct relationship between volume and value, translating to improvement in hip fracture care delivery for both surgeons and hospitals. Higher volume hospitals while lower volume surgeons perform the majority of hip fracture cases, suggesting optimisation opportunities. However, systems-based practices at the hospital level likely drive value to a greater extent than individual surgeons.

Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture

IMPORTANCE

Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience.

OBJECTIVE

To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017.

EXPOSURES

Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions.

RESULTS

Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08).

CONCLUSIONS AND RELEVANCE

Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.

Annual case volume is a risk factor for 30-day unplanned readmission after open reduction and internal fixation of acetabular fractures

BACKGROUND

Surgical fixation of acetabular fractures is technically challenging, and quality of reduction directly correlates to patient outcomes. Considering the difficulty of open reduction and internal fixation (ORIF), increased case volumes may improve patient outcomes. No studies have investigated case volume as a risk factor for readmission after acetabular fracture ORIF. The present study sought to answer the question of whether annual case volume is a risk factor for 30-day unplanned readmission after acetabular fracture ORIF, if there is an identifiable threshold number of cases most predictive of a readmission, and if differences exist between reasons for readmission between high and low-volume centers.

HYPOTHESIS

Institutions with a lower annual case volume will have a higher incidence of 30-day unplanned readmissions.

MATERIALS AND METHODS

The national readmissions database (NRD) was queried for acetabular fractures that underwent ORIF during 2016. Comorbid conditions were summed, and annual hospital case volume was identified. A receiver operating characteristic (ROC) curve was generated and the Youden index identified threshold case volume most predictive of a 30-day readmission. A multivariable logistic regression was performed with 30-day readmission as the dependent variable and case volume below the threshold an independent variable.

RESULTS

A total of 3,407 cases were included with a median age of 43. The 30-day readmission for this cohort was 6.5% (220/3407). ROC curve analysis identified 22 annual cases as the threshold value most predictive of 30-day readmission. Multivariable logistic regression identified age (Odds Ratio (OR)=1.01, p=0.005), number of comorbidities (OR=1.35, p<0.0001), and ≤22 cases (OR=1.50, p=0.006) as statistically significant risk factors for 30-day readmission. The most common reason for readmission at both high and low-volume centers was surgical site infection.

DISCUSSION

Annual case volume is a statistically significant predictor of 30-day readmission after acetabular fracture ORIF. Performing ≤22 acetabular ORIFs places patients at greater risk for a readmission. Patients at low-volume centers may be predisposed to readmission, and it is paramount to optimize patients prior to discharge, and have appropriate surgeon and hospital resources to treat these complex injuries.

LEVEL OF EVIDENCE

III, Cross-sectional study.

Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study

Objective

To assess the effect of tranexamic acid (TXA) use in hip fracture surgery.

Methods

A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost.

Results

In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost.

Conclusion

Our results are in support of a wider use of TXA in hip fracture surgery.

Level of evidence

Level III.

Effect of Surgeon and Hospital Volume on Complications After Operative Tarsal Fracture Repair

OBJECTIVE

To determine whether increased surgeon and hospital volume is associated with lower rates of complications after tarsal fractures.

DESIGN

Retrospective cohort study of the State Inpatient Databases.

SETTING

Two hundred ninety-nine hospitals in Florida (2005-2012) and New York (2006-2008).

PATIENTS/PARTICIPANTS

Four thousand one hundred thirty-two tarsal fractures that underwent fixation by 1223 surgeons.

INTERVENTION

Surgical repair of tarsal fractures.

MAIN OUTCOME MEASUREMENTS

Composite of readmission for infection requiring operative treatment, wound dehiscence, nonunion, avascular necrosis, or amputation within 2 years of the index procedure.

RESULTS

The mean age was 44 (±15) years, a majority were men (70%) and white (69%), and the mean number of Charlson comorbidities was 0.21 (±0.58). Multivariable logistic regression demonstrated a reduction in the likelihood of complications by 9% for each 5 additional surgeries performed by the operating surgeon [odds ratio (OR), 0.91 per 5 surgeries; 95% confidence interval (CI), 0.82-0.99]. Other factors associated with complications included increased age (OR, 1.23 per 10 years; 95% CI, 1.10-1.36), male sex (OR, 1.56; 95% CI, 1.12-2.17), open fractures (OR, 2.84; 95% CI, 1.92-4.19), number of Charlson comorbidities (OR, 1.23; 95% CI, 1.02-1.48), income quartile (OR, 1.48; 95% CI, 1.00-2.17), uninsured (OR, 2.47; 95% CI, 1.39-4.39), and other government program insurance (OR, 1.52; 95% CI, 1.06-2.18).

CONCLUSIONS

We observed a significant inverse relationship between surgeon volume and complication rates when controlling for patient and injury characteristics. In contrast to previous research, a volume-outcome relationship was not observed at the hospital level. These results suggest that such complex injuries should be triaged to the most experienced providers.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transfer status in geriatric hip fracture surgery - An independent risk factor associated with 30-day mortality, re-operations and complications

BACKGROUND

A significant proportion of patients undergoing hip fracture surgery are transferred from other locations. With no current orthopedic literature present, we sought to study the impact of transfer location on 30-day outcomes following geriatric hip fracture surgery.

MATERIALS & METHODS

The 2015-2016 ACS-NSQIP database was queried using CPT codes to retrieve records of geriatric patients undergoing hip fracture surgery (total hip arthroplasty/THA, hemiarthroplasty/HA and open reduction internal fixation/ORIF). Transfer status was defined into four groups - 1) No transfer (admitted from home), 2) From acute care hospital, 3) From nursing home/chronic care facility and 4) From outside emergency department (ED). Patients with missing data were excluded. A total of 31,218 patients were included in the final cohort.

RESULTS

Out of 31,218 patients - 23,659 (75.8%) were admitted from home, 1574 (5.0%) from acute care hospitals, 3299 (10.6%) from nursing home/chronic care facilities and 2686 (8.6%) from outside EDs. Following adjusted analysis, transfer from nursing home vs. home was associated with higher odds of 30-day mortality (OR 1.57 [95% 1.36-1.80]; p < 0.001), 30-day re-operations (OR 1.36 [95% CI 1.10-1.68]; p = 0.005), septic shock (OR 1.58 [95% CI 1.07-2.32]; p = 0.021), sepsis (OR 1.45 [95% CI 1.05-1.99]; p = 0.023) and urinary tract infection (OR 1.21 [95% CI 1.02-1.42]; p = 0.025). Additionally, transfer from outside ED vs. home was also associated with higher odds of 30-day mortality (OR 1.26 [95% CI 1.06-1.50]; p = 0.010).Transfer from any location (acute care hospital, nursing home and outside ED) was significantly associated with higher odds of non-home discharge (p < 0.001).

CONCLUSION

Transfer status is an important risk factor associated with 30-day mortality and morbidity in geriatric patients undergoing hip fracture surgery. The findings stress the need for recognition of these patients as being a high-risk group to allow enhanced medical optimization in an attempt to minimize the risk of poor outcomes.

Fewer Hospitals Provide Operative Fracture Care to Medicaid Patients Than Otherwise-Insured Patients in 4 Large States

OBJECTIVE

To determine whether Medicaid patients receive operative fracture care at an equal number of hospitals as otherwise-insured patients and to compare travel distances between Medicaid and otherwise-insured patients.

DESIGN

Retrospective, population-based cohort study of administrative health data.

SETTING

One thousand seventy-five hospitals in California, Florida, New York, and Texas.

PARTICIPANTS

Two hundred forty thousand three hundred seventy-six patients who underwent open reduction and internal fixation of a fracture of the radius/ulna, tibia/fibula, or humerus between 2006 and 2010 in Texas or New York, or between 2010 and 2014 in California or Florida.

INTERVENTION

Open reduction and internal fixation of the radius/ulna, tibia/fibula, or humerus.

MAIN OUTCOME MEASUREMENTS

The number of unique hospitals visited and the distance traveled for care were compared by payer status and admission acuity. The distance traveled was also stratified by urban versus rural geographic area.

RESULTS

In nonemergent settings, 7%-16% fewer hospitals saw Medicaid patients than otherwise-insured patients. In emergent settings, the gap between the number of hospitals seeing Medicaid and otherwise-insured patients was less than 5% in every state except Texas, where the gap was 11%-14%. The Medicaid and Medicare groups had longer travel distances in the nonemergent setting than in the emergent setting. Medicaid patients did not travel longer distances than otherwise-insured patients except in Texas, where they traveled 3-5 miles further than otherwise-insured patients in the nonemergent, urban setting.

CONCLUSIONS

Fewer hospitals provide operative fracture care to Medicaid patients than otherwise-insured patients, but Medicaid patients do not travel longer distances to the hospital on a population level.

LEVEL OF EVIDENCE

Prognostic Level III.

[Does hospital volume correlate with surgical process time? : Retrospective analysis of the five most common procedures for visceral surgery, trauma and orthopedic surgery and gynecology/obstetrics from the benchmarking program of the Berufsverband Deutscher Anästhesisten (BDA), Berufsverband Deutscher Chirurgen (BDC) and Verband für OP-Management (VOPM)]

BACKGROUND

Minimum volume thresholds for specific surgical procedures in German hospitals were established in 2004 but remain controversial. For the first time, this study investigated the relationship between hospital performance volume and surgical procedure duration in a multicenter approach. The question here was whether a concentration on frequently performed procedures leads to a reduction in surgical process times.

METHODS

In a retrospective analysis, the 5 most common procedures from visceral, trauma/orthopedic and gynecological/obstetrics surgery were examined in hospitals participating in a benchmarking program. For each procedure performed between 2013 and 2015, hospitals were divided into 4 groups depending on the hospital volume provided. The average surgical duration of incision to suture time was calculated between the group with "very low" hospital volume and the other three groups ("low", "high" and "very high").

RESULTS

OR cases from 75 hospitals were analyzed. The number of included cases per procedure ranged from 31,940 to 2705. The average number of operations performed in a specific procedure was 3-4 times higher in high-volume hospitals compared to very low-volume hospitals. A linear relationship between hospital volume and surgical process time only appeared to be clearly seen in laparoscopic cholecystectomy, appendectomy and arthroscopic meniscus surgery: a higher case load led to a reduction in incision to suture time. For the other procedures, the surgical process times were inconsistent between the hospital groups.

CONCLUSION

The case volume only appeared to have a direct but limited influence on incision to suture times in laparoscopic and arthroscopic procedures. Overall, the hospital performance volume appeared to be of subordinate importance in terms of OR-economics.