Comparison of rehabilitation outcomes between robot-assisted and freehand screw placement in treatment of femoral neck fractures: a systematic review and meta-analysis.

PURPOSE: To compare the postoperative rehabilitation of femoral neck fractures treated with robot-assisted nailing and freehand nailing. METHODS: We systematically searched the PubMed, EMBASE, Cochrane, China National Knowledge Infrastructure(CNKI), WanFang database, China Science and Technology Journal Database (VIP) and Web of Science databases to identify potentially eligible articles. Indispensable data such as the year of publication, country, study type, robot type, age, number of patients, sex distribution, study design, and outcome indicators were extracted. The outcome indicators of interest included healing rate, length of healing time, Harris score, operation time, frequency of X-ray fluoroscopy, frequency of guide pin insertion, and intraoperative blood loss. RevMan 5.4.1 was used for the meta-analysis. RESULTS: Fourteen studies with 908 participants were included in this meta-analysis. The results showed that in terms of healing rate (SMD = 2.75, 95% CI, 1.03 to 7.32, P = 0.04) and Harris score (SMD = 2.27, 95% CI, 0.79 to 3.75, P = 0.003), robot-assisted screw placement technique scores were higher than the traditional freehand technique. Additionally, operative time (SMD = -12.72, 95% CI, -19.74 to -5.70, P = 0.0004), healing time (SMD = -13.63, 95% CI, -20.18 to -7.08, P < 0.0001), frequency of X-ray fluoroscopy (SMD = - 13.64, 95% CI, - 18.32 to - 8.95, P < 0.00001), frequency of guide pin insertion (SMD = - 7.95, 95% CI, - 10.13 to - 5.76, P < 0.00001), and intraoperative blood loss (SMD = - 17.33, 95% CI, - 23.66 to - 11.00, P < 0.00001) were lower for patients who underwent robotic-assisted screw placement than those for patients who underwent the conventional freehand technique. CONCLUSION: Compared to the freehand nailing technique, robot-assisted nailing helps improve postoperative healing rates in patients with femoral neck fractures; shortens healing times; better restores hip function; reduces the number of intraoperative fluoroscopies, guides pin placements; reduces intraoperative bleeding; and increases perioperative safety.

A comprehensive program for enhanced management of femoral neck fractures including an enhanced recovery after surgery program: A retrospective study.

ABSTRACT: To retrospectively analyze the functional outcomes and complications in patients who underwent hip arthroplasty with enhanced recovery after surgery (ERAS) program for femoral neck fractures.Between June 2015 and May 2019, 1138 patients with femoral neck fractures were treated in our department. According to the Garden classification system, 467 cases were type III and 671 cases were type IV with an average age of 74.9 ±â€Š8.8 years (range, 59-96 years). All patients underwent hip arthroplasty with ERAS. The clinical outcomes of these patients were retrospectively analyzed at the final follow-up using the Harris hip score (HHS).The median follow-up was 21.2 months (range, 6-36 months). The mean time to surgery and the length of hospitalization after surgery were 2.4 and 2.2 days, respectively. Eight hundred and fifty-two patients (74.9%) were operated within 48 hours from admission, 1052 cases (92.4%) were discharged within 48 hours after surgery. Twelve patients (1.05%) were readmitted for prosthetic dislocation. None of the patients suffered from infection, periprosthetic fractures, and/or prosthetic loosening. The HHS at the final follow-up was 92.7 ±â€Š7.6, with an excellent or good rate of 90.2%.Patient-oriented ERAS optimizes the interventional measures during the perioperative period for geriatric patients with femoral neck fractures and can improve their short-term clinical outcomes without increased readmission rates.

Intelligent rehabilitation assistant system to promote the early functional recovery of the elderly patients with femoral neck fracture after hemiarthroplasty (HA): A protocol for a randomized controlled trial.

BACKGROUND: Femoral neck fracture is a common type of hip fracture, which has a high morbidity and mortality. Surgical treatment is the first choice. However, the functional rehabilitation after operation has not been paid enough attention. In addition, the quality of exercise is difficult to quantify, and the rehabilitation is lack of standards. Therefore, the intelligent rehabilitation assistant system which could record exercise details, might be used to evaluate the quality and adherence to the prescribed exercise to this fragile group of patients has great relevance, so as to provide new ideas for postoperative rehabilitation of hip fracture. METHODS: This is an opening, prospective, double-dummy RCT. Fifty femoral neck fractures patients, older than 65 years and are about to hospitalize for HA, will be invited to study. The sample will be divided into monitoring group and control group randomly at a 1:1 ratio. The prescribed exercises need to be done continuously for 2 weeks. The monitoring group needs additional use intelligent rehabilitation assistant system. Each subject will receive a total of 4 follow-up visits at the designated time (2 weeks, 4 weeks, 12 weeks, and 24 weeks). The following factors will be talked as dependent variables:Each subject will receive a total of 4 follow-up visits at the designated time, and the findings will be analyzed statistically considering a 5% significance level (P < .05). DISCUSSION: Exercise under monitor may improve patients compliance and exercise quality, and accelerate the rehabilitation process. This protocol reported in accordance with the CONSORT 2010 checklist and SPIRIT 2013 Checklist. TRIAL REGISTRATION: The trial is registered at Chinese Clinical Trials Registry (ChiCTR2000033213, May 24, 2020).

Translation, reliability, agreement and validity of the Turkish version of Cumulated Ambulation Score in patients with hip fracture.

OBJECTIVES: This study aims to translate and investigate the inter- rater reliability, agreement and validity of the Turkish version of the Cumulated Ambulation Score (CAS-TR) in patients with hip fracture. PATIENTS AND METHODS: This study included patients with a hip fracture of the femoral neck between July 2019 and March 2020 at the Dr. Lütfi Kirdar Kartal Training and Education Hospital, Department of Orthopedics and Traumatology, Istanbul. The CAS manual and score-sheet were translated into Turkish. An orthopedician and a physiotherapist independently administered the CAS-TR to 36 patients (12 males, 24 females; mean age 78.7 years; range, 65 to 90 years) at postoperative days one, two, three and 30. Weighted Cohen's kappa coefficient was used to measure inter-rater reliability. Turkish version of modified Barthel Index was used for analysis of validity. RESULTS: The majority of the patients had type III fracture (72.2%) according to Garden's classification. The kappa value was ≥0.90 for days one-three, the total and 30th day score of CAS-TR. The observed agreement ranged between 91.6% and 100% for all assessments. Validity analysis showed a significantly positive correlation between day two and day 30 CAS-TR and Barthel scores. CONCLUSION: We found almost perfect reliability, high percentage agreement and acceptable convergent validity of the CAS-TR. We recommend the CAS to be used as an easily applicable instrument to assess basic mobility status in Turkish patients with hip fracture. Orthopedic and geriatric patients and patients undergoing any type of surgery can be assessed with CAS for early evaluation of mobility status.

Outcome of surgery in neck of femur fracture patients with poor pre-fracture mobility.

BACKGROUND: Hip fractures are common with a UK incidence of over 70,000 cases and total healthcare costs of over £2 billion per year. Mortality rates of 10% at 30 days and up to 30% at 1-year have been reported. We wanted to assess the outcome of hip fracture surgery in patients with reduced pre-fracture mobility as this has not been exclusively studied previously. METHODS: We retrospectively reviewed 168 hip fracture patients with reduced pre-fracture mobility (wheelchair bound, bed bound, walking with 2 aids or a frame) who underwent hip fracture surgery at our institution between 2008 and 2013 using case notes, discharge letters, outpatient clinic letters and laboratory test results. Measured outcomes included 30-day renal, cardiac and respiratory morbidity as well as 30-day and 1-year mortality. RESULTS: Our study comprised 27% males and 73% females with a mean age of 82 years. The 30-day chest infection, acute renal failure and acute coronary syndrome rates were 26%, 7.7% and 4% respectively. In those patients who were either wheelchair or bed bound, 30-day and 1-year mortality rates were 11.8% and 52% respectively whereas in those who could mobilise with the help of 2 aids or frame, 30-day and 1-year mortality rates were 4.34% and 39.70% respectively. CONCLUSION: Our study highlighted increased 30-day and 1-year morbidity and mortality rates following hip fracture surgery with notable high rates of respiratory and renal complications in patients with reduced pre-fracture mobility. We would recommend pre- and postoperative optimisation with orthogeriatric review, chest physiotherapy and intravenous fluid hydration to reduce complication rates and improve morbidity and mortality.

Mobility after intertrochanteric hip fracture fixation with either a sliding hip screw or a cephalomedullary nail: Sub group analysis of a randomised trial of 1000 patients.

AIMS: The aim of this study was to determine if different patient groups have superior mobility regain following intertrochanteric hip fracture fixation with a cephomedullary nail compared to a sliding hip screw (SHS). PATIENTS AND METHODS: The present study is a subgroup analysis of patients which were enrolled into a randomized controlled trial which randomized 1000 patients with an intertrochanteric hip fracture to fixation with either a short cephomedullary nail (Targon® PF or PFT) or a SHS. In the present study the two treatment groups were dicotomised on the basis of six variables determined at the time of admission; age (<80; ≥80 years), sex, residence (admitted from own home; institutional care), mobility (mobility score ≥7 [good]; <7 [poor]), mental status (AMTS < 7 [cognitively impaired]; ≥7) and health status (ASA < 3; ≥3). The primary outcome measure was the difference between mobility score pre-fracture and mobility score during the year after hip fracture fixation. RESULTS: Patients less than 80 years of age, those admitted from their own home, cognitively intact patients and patients who mobilised without assistance pre-fracture, recovered superior mobility when fracture fixation was performed with a nail compared to a SHS. Those patients admitted from institutional care, those with significant cognitive or mobility impairment at the time of the injury did not have any significantly improved benefit in mobility regain with a nail compared to a SHS. CONCLUSION: Fixation of an intertrochanteric hip fracture with a cephomedullary nail results in superior recovery of mobility for younger patients who prior to the injury were more mobile, cognitively intact and living at home.

Weight bearing in patients with femoral neck fractures compared to pertrochanteric fractures: A postoperative gait analysis.

Early mobilization following hip fracture surgery is of superior importance especially in elderly hip fracture patients. Reduced mobilization can result in complications and increased mortality. In this study a gait analysis was performed using force-measuring insoles. We hypothesized, that patients with femoral neck fractures treated with hip replacement surgery load the affected limb more compared to patients with pertrochanteric fractures treated with fracture fixation. All patients (> 65 years) treated for a femoral neck fracture with hip replacement or a pertrochanteric fracture, respectively using fracture fixation with intramedullary nailing, were consecutively included in this study. For gait analysis, specific insole forcesensors (Loadsol®) were inserted into the footwear. Five days after surgery gait analysis was performed with a defined walking distance and all patients were instructed to transpose full weight. 20 patients following hip replacement surgery and 27 patients following intramedullary nailing were included. The hip replacement group loaded the affected limb with an average of 74.01% (SD 13.6) of bodyweight, while the fracture fixation group loaded a significantly reduced average of 62.70% (SD 8.3; p = 0.002). The results of the present study indicate that patients suffering from pertrochanteric fractures following fracture fixation are struggling to fully load the affected leg compared to patients suffering from femoral neck fractures treated with hip replacement surgery. The focus of further studies should concentrate on alternative analgesia and verify the cause of the observed difference in order to facilitate early full weight bearing especially in hip fracture patients following fracture fixation. The results indicate that in elderly patients, the fracture pattern and thus the surgical approach lead to a different weight bearing pattern. The primary therapeutic goal for elderly patients must be early mobilization at full weight bearing.

[Effect of early preoperative mobilization on rehabilitation of the elderly patients with hip fractures after operation].

OBJECTIVE: To evaluate the effect of early preoperative mobilization on the rehabilitation of the elderly patients with hip fractures after operation. METHODS: The clinical data of 16 elderly patients with hip fractures between February 2017 and April 2018 who met the selection criteria was retrospectively analyzed. There were 8 males and 8 females, with an average age of 80.3 years (range, 69-90 years). There were 8 cases of intertrochanteric fracture and 8 cases of femoral neck fracture. The preoperative American Society of Anesthesiologists (ASA) scored 2.94±0.43. There were 3 cases of cardiovascular and cerebrovascular diseases, 6 cases of essential hypertension, 5 cases of respiratory diseases, 3 cases of diabetes, and 2 cases of other system diseases. The time from injury to admission was 4 hours to 14 days with an average of 39.5 hours. On the day of admission or on the first day after admission, the patient started to exercise on the floor underwent analgesia treatment. And the patients were treated with closed reduction (9 cases) or artificial hip arthroplasty (7 cases). The time from admission to operation was 4 to 25 days, with an average of 7.4 days. At the time of admission, after the first ground movement before operation, on the second day after operation, and at last follow-up, the Barthel Index was used to assess the patients' self-care ability, and Barthel effectiveness (BE) was calculated. The complications were observed and recorded during follow-up. RESULTS: All 16 patients underwent operation successfully. The hospital stay was 8 to 24 days, with an average of 14.1 days. All patients were followed up 2.5-16.0 months with an average of 6.5 months. One patient developed postoperative pulmonary infection; the remaining patients had no surgical-related complications. No patient died during the follow-up. The Barthel Index scored 30.63±5.56 at admission, 53.13±9.50 after the first ground movement before operation, 60.63±6.09 on the second day after operation, and 96.25±4.84 at last follow-up. There were significant differences in Barthel Index scores between different time points ( P<0.05). The BE was 0.23±0.06 after the first ground movement before operation, 0.30±0.04 on the second day after operation, and 0.66±0.06 at last follow-up. There were significant differences in BE between different time points ( P<0.05). CONCLUSION: For elderly patients with hip fractures who have long waiting time before operation, early preoperative mobilization has a positive impact on patients' activities of daily living.

Good function and high patient satisfaction at mean 2.8 years after dual mobility THA following femoral neck fracture: a cross-sectional study of 124 patients.

AIMS: Our aim was to investigate function, health status and satisfaction in patients treated with primary dual mobility (DM) total hip arthroplasty (THA) after displaced femoral neck fracture (FNF). PATIENTS AND METHODS: From 2005-2011, 414 consecutive FNF patients received Saturne DM THA. At a minimum of 1-year follow-up, 124 (95 women) were evaluated with Oxford Hip Score (OHS), Harris Hip Score (HHS), health-related quality of life (HRQoL) measure (EQ-5D) and two functional tests: Timed Up and Go (TUG) and Sit to Stand 10 times (STS). The FNF patients were matched 1:2 by age, sex and surgery date with patients receiving THA due to osteoarthrosis (OA group) and 1-year OHS and EQ5D were compared. FNF patients were matched by age and sex with the general population index (GPI) for EQ-5D comparison. RESULTS: Patient age at surgery after FNF was mean 74.8 (range 30-92) years. At mean follow-up of 2.8 (range 1.0-7.7) years, mean EQ-5D score was 0.79 (SD 0.15) in the FNF group, which was similar to the matched GPI (p = 0.4), but lower (p = 0.014) compared to the OA group. Mean OHS was 36.4 (SD 9.5) in the FNF group and 38.4 (SD 7.2) in the OA group (p = 0.18). HHS in the FNF group was 78.7 (SD 15.5). Mean TUG time was 13.5 (SD 4.9) secs, and mean STS was 37.9 (SD 15.3) secs. Eighty nine percent (n = 111) of FNF patients were satisfied with the operation result. CONCLUSION: DM THA following displaced FNF provides a good functional result and quality of life in addition to high patient satisfaction.

Femoral Neck Stress Fracture in a Female Runner.

A 23-year-old woman was referred to physical therapy by her primary care physician for a 4-week history of right groin pain that had progressively worsened while training for a half-marathon. Before the physical therapy referral, the primary care physician ordered radiography of the right hip, which was unremarkable for fracture. Following examination, the physical therapist suspected osseous or soft tissue abnormality and requested that the primary care physician order magnetic resonance imaging without contrast, which revealed a femoral neck stress fracture. J Orthop Sports Phys Ther 2018;48(4):343. doi:10.2519/jospt.2018.7479.

Optimization of perioperative management of proximal femoral fracture in the elderly.

Proximal femoral fracture in elderly subjects is a major event that is life-threatening in the medium-to-long term. Advanced age, male gender and number of comorbidities largely account for high mortality and require geriatric expertise. Protein-energy malnutrition and bone demineralization increase mortality. Mortality can, on the other hand, be reduced by acting on two variables accessible to medical intervention: daily activities and nutritional status. Functional and neurocognitive assessment allow the risk of dependency to be evaluated, and global geriatric work-up can prevent sudden breakdown of homeostasis. In the emergency setting, pain is to be alleviated, polymedication and anticoagulation therapy checked, and instability (notably cardiac and pulmonary) and confusion syndrome screened for on geriatric and anesthesiologic opinions. Surgery should be implemented without delay, within 48hours of admission, preferably using multimodal anesthesia. The technique should be geared to allow early weight-bearing and mobilization. The most comprehensive care plan involves team-work between emergency physicians, surgeons, orthopedic specialists, anesthesiologists, geriatricians, pharmacists, rehabilitation specialists and nursing staff, to reduce mortality and readmission and improve functional results. Post-fracture coordination seeks to prevent falls and further fractures and to treat bone demineralization.

Good functional outcome but not regained health related quality of life in the majority of 20-69 years old patients with femoral neck fracture treated with internal fixation: A prospective 2-year follow-up study of 182 patients.

BACKGROUND AND PURPOSE: Prospective studies on patient related outcome in patients <70years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20-69years old patients with a FNF treated with internal fixation. PATIENTS AND METHODS: 182 patients, 20-69years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations. RESULTS: At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p=0.15). Of the patients with displaced fracture (n=120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n=50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5Dindex in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p<0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p<0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p<0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p<0.001). INTERPRETATION: Two thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.

Rehabilitation of Patients with Hip Joint Arthroplasty (Late Post-surgery Period - Hospital Rehabilitation).

BACKGROUND: Hip joint replacement (endoprosthesis, alloplasty) has become one of the most frequent surgery interventions of the 20th century. AIM: To conduct rehabilitation therapy in the late post-surgery period of hospital rehabilitation (45 days after surgery), to track patients' progress and measure the results. MATERIALS AND METHODS: One hundred and fifty-two patients with hip joint endoprosthesis were included in the study. All underwent surgery and rehabilitation at the Department of Clinical Rehabilitation of the Physical and Rehabilitation Medicine Clinic at Doctor G. Stranski University Hospital, Pleven. Kinesitherapy included therapeutic massage, isometric exercises for gluteal and hip muscles, isotonic exercises for the hip and the knee joint, breathing exercises, analytical gymnastics, exercises for balance and posture stability; gait control, exercises with gym equipment; occupational exercises included all activities of daily living (ADL) that were practiced at home; treatment with performed physical factors included applying magnetic field, interferential current therapy, electrostimulation of the m. quadriceps femoris and the gluteal muscles. RESULTS: The scores from the pain visual analog scale (VAS), the muscle strength test and the test for the movement volume of the hip joint were obtained at the beginning and at the end of the rehabilitation process and stored in an individual file for each patient. CONCLUSION: The results of the present study suggest that the complex rehabilitation program (kinesitherapy, performed physical factors and occupational therapy) can result in a considerably faster recovery and ensures that patients reach optimal functional results.

A comparison of treatment setting for elderly patients with hip fracture, is the geriatric ward superior to conventional orthopedic hospitalization?

INTRODUCTION: Hip fractures in the elderly are a major cause of morbidity and mortality. The treatment settings of these patients may change their outcomes. The aim of this study is to compare the outcomes of patients with displaced femoral neck fractures who were admitted to the orthopedic vs. geriatric wards. PATIENTS AND METHODS: A retrospective study was conducted on 217 consecutive older patients with 219 displaced femoral neck fractures admitted either to the orthopedic or the geriatric ward between Jan. 2013 and Jun. 2015. Information regarding demographic, medical history, surgical management, hospitalization, and one year readmissions and mortality data was retrieved from electronic charts. RESULTS: 102 hemiarthroplasty patients were admitted to the orthopedic ward and 117 to the geriatric ward. Patients' characteristics, including age, living arrangements, mobility status and the Charlson Comorbidity Index were similar between groups. Patients from the orthopedic ward had shorter hospitalization time (9±5.1 vs. 10.8±6.7days, p=0.022) and presented a lower in-hospital complication rates (0.6±0.96 vs. 1±1.9, p=0.022), namely fewer events of urinary retentions, urinary tract infections and pneumonias (8.8% vs. 23.9%, p=0.004, 3.9% vs. 14.5%, p=0.010 and 2.9% vs. 12.2%, p=0.034, respectfully). Readmission rates were similar. Neither in hospital nor one year mortality rates differed between groups. CONCLUSIONS: Our study found that geriatric care was not superior to orthopedic directed management in the treatment of elderly patients with hip fractures in terms of in-hospital complications, and hospitalization times.

Neck of femur fractures in the elderly: Does every hour to surgery count?

OBJECTIVES: To determine if early surgery before 12h confers a survival or length of stay benefit for patients with neck of femur (NOF) fractures. DESIGN: Retrospective review of prospectively collected data. SETTING: District general hospital. PATIENTS: 1913 patients aged over 60 admitted with a fractured NOF who underwent surgery between 2011 and 2015. Mean age was 83.9 years. 73.7% were female. INTERVENTION: Patients had surgery for fractured NOF with data collected on demographics, mortality and length of stay. MAIN OUTCOME MEASUREMENTS: Data collected included gender, age, ASA grade, fracture anatomy, surgery, time to surgery, days spent in acute hospital and rehabilitation settings and 30-day mortality. Statistical analysis was used to identify independent predictors of mortality and length of stay. RESULTS: 30-day mortality was 6.1% and the mean hospitalisation time was 13±11.3days for the acute hospital and 20.2±17.2days for the trust. Operations were performed at a mean of 23.8±14.8h after presentation. Age, gender, ASA grade and type of fracture were independent predictors of either mortality or length of stay. Timing of surgery had an association with mortality but this only reached statistical significance at 24h. In line with previous studies we analysed time to surgery in 12h blocks. We also used logistic regression, recognizing time as a continuous variable, which revealed that every hour of delay to surgery increased the mortality risk by 1.8%. CONCLUSIONS: While every hour of delay increased mortality risk, the association with mortality only became statistically significant when delaying over 24h. This supports a pragmatic approach, with surgery as soon as medically possible without a race to theatre. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Prognostic value of the sliding length of cephalocervical screws to predict the risk of non-union after osteosynthesis: a retrospective analysis of 86 patients with intracapsular femoral neck fractures.

BACKGROUND: Here, we assessed the prognostic value of the early sliding length (ESL) for predicting the risk of non-union after internal fixation of femoral neck fractures (FNFs) by Dual SC Screws (DSCS). METHODS: A retrospective analysis of 86 patients with intra-capsular FNFs was performed. They underwent osteosynthesis by DSCS at our institution between 2008 and 2013 with a minimum follow-up duration of 6 months. Preoperative displacement, fracture reduction quality, ESL of screws at 2 weeks postoperatively, and correlation of non-union with the ESL of screws were evaluated. RESULTS: Bone union without complications was achieved in 74 patients (86.0%), whereas 12 patients (14.0%) showed non-union. The ESL was significantly longer in the non-union group (proximal 3.94 ± 2.79 mm, distal 4.03 ± 3.16 mm) than in the union group (proximal 0.98 ± 1.85 mm, distal 1.01 ± 1.84 mm, P = 0.0001* for proximal, P < 0.0001* for distal). The ESL was significantly associated with non-union, both in the proximal [P = 0.0002, unit odds ratio (OR) 1.58, 95% confidence interval (CI) 1.23-2.16] and distal screws (P = 0.0002, unit OR 1.53, 95% CI 1.21-2.02). The areas under the ROC curves for the ESL of proximal and distal screws were 0.845 and 0.867, respectively; the cut-off values to predict non-union were 1.0 mm (sensitivity 91.7% and specificity 74.3%) and 1.4 mm (sensitivity 83.3% and specificity 81.1%), respectively. CONCLUSIONS: In this study, the ESL was a good predictor of postoperative non-union in patients with FNFs fixed by DSCS.

Intracapsular hip fractures in the elderly. Do we know what is important?

BACKGROUND: Hip fractures in the elderly are a common reason for admission to the department of orthopaedic surgery, this condition asks an important part of health resources and is associated with high levels of co-morbidity and mortality. Many improvements have been introduced in the treatment of these patients, preoperative regional analgesia, intensive physical therapy, interdisciplinary care program; but still remain unresolved gaps. The aim of this study is to document the natural history of early versus delayed surgical intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: A sample of 499 patients admitted in our Institution was prospectively reviewed between February 2008 and February 2013. Preoperatively characteristics and functional data were assessed in relation with time to surgery (focused on mortality and ability to walk at first year). RESULTS: The ability to walk and activities of daily living (functional results) were not associated with surgical delays (surgery before 24h from admission, surgery among 24h and 72h from admission and surgery later than 72h). However, ASA class, Parkinson disease and age were significantly associated with poor functional results. In the same way, mortality at 1year was not associated with time to surgery, but ASA class was associated with significant risk factor of 1 year-mortality. CONCLUSIONS: ASA class, Parkinson disease and age are independent predictor of poor functional outcomes after intracapsular hip fracture. In addition, ASA class is an independent predictor of mortality. Patients with poor functional status before fracture and older than 75 years would benefit from geriatric and rehabilitation intervention immediately after surgery.

Exploring factors that influence the spread and sustainability of a dysphagia innovation: an instrumental case study.

BACKGROUND: Swallowing difficulties challenge patient safety due to the increased risk of malnutrition, dehydration and aspiration pneumonia. A theoretically driven study was undertaken to examine the spread and sustainability of a locally developed innovation that involved using the Inter-Professional Dysphagia Framework to structure education for the workforce. A conceptual framework with 3 spread strategies (hierarchical control, participatory adaptation and facilitated evolution) was blended with a processual approach to sustaining organisational change. The aim was to understand the processes, mechanism and outcomes associated with the spread and sustainability of this safety initiative. METHODS: An instrumental case study, prospectively tracked a dysphagia innovation for 34 months (April 2011 to January 2014) in a large health care organisation in England. A train-the-trainer intervention (as participatory adaptation) was deployed on care pathways for stroke and fractured neck of femur. Data were collected at the organisational and clinical level through interviews (n = 30) and document review. The coding frame combined the processual approach with the spread mechanisms. Pre-determined outcomes included the number of staff trained about dysphagia and impact related to changes in practice. RESULTS: The features and processes associated with hierarchical control and participatory adaptation were identified. Leadership, critical junctures, temporality and making the innovation routine were aspects of hierarchical control. Participatory adaptation was evident on the care pathways through stakeholder responses, workload and resource pressures. Six of the 25 ward based trainers cascaded the dysphagia training. The expected outcomes were achieved when the top-down mandate (hierarchical control) was supplemented by local engagement and support (participatory adaptation). CONCLUSIONS: Frameworks for spread and sustainability were combined to create a 'small theory' that described the interventions, the processes and desired outcomes a priori. This novel methodological approach confirmed what is known about spread and sustainability, highlighted the particularity of change and offered new insights into the factors associated with hierarchical control and participatory adaptation. The findings illustrate the dualities of organisational change as universal and context specific; as particular and amendable to theoretical generalisation. Appreciating these dualities may contribute to understanding why many innovations fail to become routine.

Auckland City Hospital's Ortho-Geriatric Service: an audit of patients aged over 65 with fractured neck of femur.

AIMS: The aims of this audit were to collect the Minimum Data Set outlined by the Australia New Zealand Hip Fracture Registry (ANZHFR), assess patient characteristics, analyse process of care, and evaluate how this compares to NICE guidelines for hip fracture care, as well as to Auckland Hospital data from 2007. METHOD: Retrospective case record audit of patients with fractured neck of femur aged 65 years and over admitted under Orthopaedics over a 4-month period in 2013. RESULTS: Ninety-one patients were audited; mean age was 83 years, 68% were female. Both inpatient and 30-day mortality was 5%. 120-day mortality was 15%. Seventy-six percent of patients were admitted from ED within the national health target prescribed period of 6 hours. Only one patient was treated non-surgically. Eighty-six percent had surgery within 48 hours of admission. Eighty-two percent of patients had rehabilitation and treatment by Older People's Health. Of those living at home pre-fracture, 76% returned home on discharge. Thirty-seven percent of patients were able to walk unaided prior to hip fracture, but only 1% on discharge. Average overall length of stay was 22 days. Bisphosphonates were prescribed for 56% of patients. CONCLUSIONS: Compared to 2007, Auckland City Hospital has demonstrated a significant improvement in the rate of provision of timely surgery for hip fracture patients. Most patients are receiving the guideline recommended fracture-specific surgical interventions. The assessment and treatment of osteoporosis needs further attention.