Implementation of supplemental physiotherapy following hip fracture surgery: a protocol for the process evaluation of a randomised controlled trial.

BACKGROUND: Patient outcomes following low-trauma hip fracture are suboptimal resulting in increased healthcare costs and poor functional outcomes at 1 year. Providing early and intensive in-hospital physiotherapy could help improve patient outcomes and reduce costs following hip fracture surgery. The HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER) trial will compare usual care physiotherapy to intensive in-hospital physiotherapy for patients following hip fracture surgery. The complex environments in which the intervention is implemented present unique contextual challenges that may impact intervention effectiveness. This study aims to complete a process evaluation to identify barriers and facilitators to implementation and explore the patient, carer and clinician experience of intensive therapy following hip fracture surgery. METHODS AND ANALYSIS: The process evaluation is embedded within a two-arm randomised, controlled, assessor-blinded trial recruiting 620 participants from eight Australian hospitals who have had surgery for a hip fracture sustained via a low-trauma injury. A theory-based mixed method process evaluation will be completed in tandem with the HIPSTER trial. Patient and carer semi-structured interviews will be completed at 6 weeks following hip fracture surgery. The clinician experience will be explored through online surveys completed pre- and post-implementation of intensive therapy and mapped to domains of the Theoretical Domains Framework (TDF). Translation and behaviour change success will be assessed using the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) framework and a combination of qualitative and quantitative data collection methods. These data will assist with the development of an Implementation Toolkit aiding future translation into practice. DISCUSSION: The embedded process evaluation will help understand the interplay between the implementation context and the intensive therapy intervention following surgery for low-trauma hip fracture. Understanding these mechanisms, if effective, will assist with transferability into other contexts and wider translation into practice. TRIAL REGISTRATION: ACTRN 12622001442796.

HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER): a protocol for a randomised controlled trial.

INTRODUCTION: Hip fractures result in substantial health impacts for patients and costs to health systems. Many patients require prolonged hospital stays and up to 60% do not regain their prefracture level of mobility within 1 year. Physical rehabilitation plays a key role in regaining physical function and independence; however, there are no recommendations regarding the optimal intensity. This study aims to compare the clinical efficacy and cost-effectiveness of early intensive in-hospital physiotherapy compared with usual care in patients who have had surgery following a hip fracture. METHODS AND ANALYSIS: This two-arm randomised, controlled, assessor-blinded trial will recruit 620 participants who have had surgery following a hip fracture from eight hospitals. Participants will be randomised 1:1 to receive usual care (physiotherapy according to usual practice at the site) or intensive physiotherapy in the hospital over the first 7 days following surgery (two additional sessions per day, one delivered by a physiotherapist and the other by an allied health assistant). The primary outcome is the total hospital length of stay, measured from the date of hospital admission to the date of hospital discharge, including both acute and subacute hospital days. Secondary outcomes are functional mobility, health-related quality of life, concerns about falling, discharge destination, proportion of patients remaining in hospital at 30 days, return to preadmission mobility and residence at 120 days and adverse events. Twelve months of follow-up will capture data on healthcare utilisation. A cost-effectiveness evaluation will be undertaken, and a process evaluation will document barriers and facilitators to implementation. ETHICS AND DISSEMINATION: The Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients and carers. TRIAL REGISTRATION NUMBER: ACTRN12622001442796.

The Translated Proximal Humerus Fracture: A Comparison of Operative and Nonoperative Management.

OBJECTIVES: To report on the long-term outcomes of the management of translated proximal humerus fractures. DESIGN: A prospective cohort study was conducted from January 2010 to December 2018. SETTING: Academic Level 1 trauma center. PARTICIPANTS/PATIENTS: A total of 108 patients with a proximal humerus fracture with ≥100% translation, defined as no cortical bony contact between the shaft and humeral head fragments, were included. INTERVENTION: Patients were managed nonoperatively with sling immobilization or with operative management as determined by the treating surgeon. MAIN OUTCOME MEASURES: Outcome measures were the Oxford Shoulder Score, EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, nonunion/malunion, and avascular necrosis. RESULTS: Of the 108 patients, 76 underwent operative intervention and 32 were managed nonoperatively. The mean (SD) age in the operative group was 54.3 (±20.2) years and in the nonoperative group was 73.3 (±15.3) years ( P < 0.001). There was no association between Oxford Shoulder Score and management options (mean 38.5 [±9.5] operative versus mean 41.3 [±8.5] nonoperative, P = 0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference was 0.16 (95% CI, 0.04-0.27; P = 0.008); EQ-5D VAS adjusted mean difference was 19.2 (95% CI, 5.2-33.2; P = 0.008). Operative management was associated with a lower odds of nonunion (adjusted OR 0.30; 95% CI, 0.09-0.97; P = 0.04), malunion (adjusted OR 0.14; 95% CI, 0.04-0.51; P = 0.003), and complications (adjusted OR 0.07; 95% CI, 0.02-0.32; P = 0.001). CONCLUSION: Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes after surgical fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness of a purpose-built ward environment and new allied health model of care for major trauma.

BACKGROUND: Targeted rehabilitation within the acute inpatient setting could have a substantial impact on improving outcomes for major trauma patients. The aim of this study was to investigate the cost-effectiveness of the introduction of a purpose-built ward environment, and a new allied health model of care (AHMOC) delivered in the acute inpatient setting, in a major trauma population. METHODS: The statewide trauma registry, the trauma center's data warehouse, and electronic medical record data were used for this observational study. There were three phases: baseline, new ward, and new AHMOC. Cost-effectiveness was measured as cost per quality-adjusted life year using preinjury, hospital discharge, 1-month and 6-month 5-level, EQ-5D utility scores. Total costs included initial acute and inpatient rehabilitation care, as well as outpatient, readmission and ED presentations to 6-months. RESULTS: Four hundred eleven patients were included. Case-mix was stable between phases. The median (IQR) number of allied health services received by patients was 8 (5-17) at baseline, 10 (5-19) in the new ward phase, and 17 (9-23) in the AHMOC phase. The proportion discharged to rehabilitation was 37% at baseline, 45% with the new ward and 28% with the new AHMOC. Mean (SD) total Australian dollar costs were $69,335 ($141,175) at baseline, $55,943 ($82,706) with the new ward and $37,833 ($49,004) with the AHMOC. The probability of the AHMOC being cost-effective at a willingness-to-pay threshold of $50,000 per quality-adjusted life year was 99.4% compared with baseline and 98% compared with the new ward. CONCLUSION: The new allied health model of care was found to be a cost-effective intervention. Uptake of this model of allied health care at other trauma centers has the potential to reduce the cost and burden of major trauma. LEVEL OF EVIDENCE: Economic and Value-based Evaluations; Level III.

Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients.

Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR). Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery. Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032). Conclusion The EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record. What is known about the topic? Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record. What does this paper add? Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement. What are the implications for practitioners? The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.

The AWESCORE, a patient-reported outcome measure: development, feasibility, reliability, validity and responsiveness for adults with cystic fibrosis.

BACKGROUND: Quality of life has improved dramatically over the past two decades in people with cystic fibrosis (CF). Quantification has been enabled by patient-reported outcome measures (PROMs); however, many are lengthy and can be challenging to use in routine clinical practice. We propose a short-form PROM that correlates well with established quality-of-life measures. METHODS: We evaluated the utility of a 10-item score (AWESCORE) by measuring reliability, validity and responsiveness in adults with CF. The questions were developed by thematic analysis of survey questions to patients in a single adult CF centre. Each question was scored using a numerical rating scale 0 to 10. Total scores ranged from 0 to 100. Test-retest reliability was assessed over 24 h. To determine validity, comparisons were sought between stable subjects and those in pulmonary exacerbation, and between AWESCORE and Cystic Fibrosis Questionnaire - Revised (CFQ-R). Responsiveness to pulmonary exacerbation in individual subjects was evaluated. RESULTS: Five domains, each with two questions, were identified for respiratory, physical, nutritional, psychological and general health. A total of 246 consecutive adults attending the outpatient clinic completed the AWESCORE. Scores were higher during clinical stability compared to pulmonary exacerbation (mean± sd): 73±11 versus 48±11 (p<0.001). Each domain scored worse during an acute exacerbation (p<0.001). No differences in reliability were observed in scores on retesting using Bland-Altman comparison. The CFQ-R scores (mean±sd: 813±125) and AWESCORE (81±13) were moderately correlated (Pearson's r=0.649; p=0.002). CONCLUSIONS: The AWESCORE is valid, reliable and responsive to altered health status in CF.

Incidence of lower limb amputation in Central Australia.

Objective The aims of this study were to review the demographic details of those who have undergone lower limb amputation (LLA) surgery in Central Australia and determine the region-specific age-adjusted incidence rate of LLA. Methods A retrospective audit of service users who underwent LLA in a Central Australian hospital from 2012 to 2017 was undertaken. Demographic, operative and postoperative outcomes data were collected. The age-adjusted incidence rate of LLA was determined using the direct method. Demographic data were analysed using descriptive parametric analysis. Results In the period 2012-17, 166 service users underwent a total of 291 amputations in 231 episodes of care (hospital admissions). The age-adjusted incidence rate of LLA was 87.4 per 100000 for females and 104.6 per 100000 for males in this region. In total, 84% (n=140) of those requiring amputation surgery identified as Aboriginal Australians (P<0.001), 54% (n=75) of whom were female. Aboriginal Australians who underwent LLA were, on average, 13 years younger and were more likely to have type 2 diabetes (P<0.001) and require renal dialysis (P<0.001) than the non-Aboriginal Australian cohort. Of the Aboriginal Australians who underwent LLA, 82% (n=103) lived very remotely (>100km from the central town's centre), compared with 23% of non-Aboriginal Australians (P<0.001). In addition, 46% (n=64) of Aboriginal Australians who underwent LLA required renal dialysis. Those requiring renal dialysis were more likely to require subsequent amputation (P=0.014) and had a higher mortality rate following amputation (P=0.031). Partial foot amputation was the most common level of amputation in Central Australia (38%). Conclusions Central Australia appears to have the highest incidence rate of LLA for any region in Australia, with Aboriginal Australians, particularly females and those undergoing renal dialysis, being disproportionately represented. Further studies should aim to determine targeted, culturally safe and successful methods of diabetic foot ulcer prevention, early detection and management with a view to reducing the high amputation rates for these cohorts. What is known about the topic? Large health inequalities between Aboriginal and non-Aboriginal Australians exist. Aboriginal Australians are currently fourfold as likely as non-Aboriginal Australians to have type 2 diabetes (T2D), increasing their risk of LLA. There is a geographical variance in the incidence of LLA in Australia; the Northern Territory is overrepresented, with rates two- to threefold higher than that of the national average. Regional incidence rates are not currently known. What does this paper add? This study showed that the age-adjusted incidence rate for LLA in Central Australia is significantly higher than in other regions in Australia. Most LLA surgeries undertaken in Central Australia were performed for Aboriginal Australians who have T2D, with a disproportionate representation of females and those requiring renal dialysis. What are the implications for practitioners? This study shows that there is a need for further research and preventative measures to address the high rates of LLA among Aboriginal Australians, particularly for females and those with renal impairment. These groups could benefit from targeted, culturally safe approaches to early identification, referral and management of lower limb ulceration by relevant service providers.

Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures.

OBJECTIVES: To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes. DESIGN: Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data. SETTING, PARTICIPANTS: Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016. MAIN OUTCOME MEASURES: Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome. RESULTS: Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%). CONCLUSIONS: Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials.

Outcomes of total hip arthroplasty surgery in heart and lung transplant recipients.

BACKGROUND: Traditionally, arthroplasty in heart and lung transplant patients has been undertaken to manage transplant-related complications. More recently, arthroplasty is increasingly being performed for end-stage osteoarthritis. This study reviewed short-term outcomes and complications of total hip arthroplasty (THA) in heart and lung transplant recipients. METHODS: A retrospective cohort of heart and lung transplant recipients who underwent THA was identified using ICD-10 coding. Post-operative complications and hospital outcomes were collected using the patient medical record. RESULTS: Thirteen patients underwent 17 primary THA between 2008 and 2017, including five for osteoarthritis and 12 for femoral head avascular necrosis. Of the 13 patients, nine were bilateral sequential lung transplant recipients and four were orthotopic heart transplant recipients. The mean patient age was 61 years, with nine being male. Overall, five patients had one post-operative complication with eight having two or more complications. Surgical complications included three intraoperative fractures, three patients with superficial infection and one with deep infection requiring surgery. Seven patients had significant bleeding requiring blood transfusion. Prosthetic dislocations occurred in two patients, with one patient requiring revision surgery (developing a joint infection). Other complications included one pulmonary embolism, two episodes of pneumonia and six episodes of acute kidney injury, whilst three patients developed post-operative delirium. At 6-week follow-up, five patients had ongoing pain and seven had limitations with mobility. At 12-month follow-up, three patients reported ongoing pain. CONCLUSION: Complications following THA after transplant are common. The risks and benefits of THA should be carefully considered preoperatively in this cohort.

HIP4Hips (High Intensity Physiotherapy for Hip fractures in the acute hospital setting): a randomised controlled trial.

OBJECTIVES: To investigate the effects of intensive acute hospital physiotherapy for patients with isolated hip fractures. DESIGN, SETTING: Single-institution, prospective, randomised trial at a level 1 trauma centre in Melbourne, March 2014 - January 2015. PARTICIPANTS: 92 patients aged 65 years or more with isolated hip fractures. Patients were excluded if the fracture was subtrochanteric or pathological, or if post-operative orders required the patient to be non-weight-bearing on the operated leg. INTERVENTIONS: Randomisation to usual care physiotherapy (daily; control group) or intensive physiotherapy (three times daily; intervention group). MAIN OUTCOME MEASURES: Outcomes were assessed at post-operative Day 5, at discharge, and at 6 months. The primary outcome was the modified Iowa Level of Assistance (mILOA) score, with other outcome measures including Timed Up and Go test performance and hospital length of stay (LOS). RESULTS: After controlling for sex, anaesthetic type and home setting, the between-group difference in Day 5 mILOA score favoured the intervention group (mean difference v control group, -2.7 points; P = 0.04). Hospital LOS was also shorter for the intervention group (median, 24.4 days v 35.0 days; P = 0.01). A Cox proportional hazard model that controlled for potential confounders indicated that the probability of discharge was greater for intervention group patients at all time points following surgery (P < 0.001). Re-admission and complication rates and 6-month outcomes for the two groups were not significantly different. CONCLUSIONS: Intensive acute hospital physiotherapy is safe and reduces hospital LOS after an isolated hip fracture. This has the potential to improve bed flow, given the large numbers of inpatient beds occupied by this patient population. TRIAL REGISTRATION: Clinical Trials Registry #NCT02088437.

Trampoline related injuries in adults.

INTRODUCTION: Trampoline-related injuries in adults are uncommon. Participation in trampolining is increasing following its admission as a sport in the Olympics and the opening of local recreational trampoline centres. The aim of this study was to assess the number and outcomes of adult trampoline-related orthopaedic injuries presenting to four trauma hospitals in Victoria. METHODS: A cohort study was performed for the period 2007-2013. Adult patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who had sustained a trampolining related injury were included in this study. Descriptive analyses were used to describe the patient population, the injuries sustained and their in-hospital and 6-month outcomes. RESULTS: There was an increase in trampolining injuries from 2007 (n=3) to 2012 (n=14) and 2013 (n=18). Overall, fifty patients with a median age of 25 (range 16-66) were identified. Thirty-five patients (70%) had lower limb injuries, 20 patients (40%) had spinal injuries and one patient had an upper limb injury. Thirty-nine patients (78%) required surgery. Fractures of the tibia (n=13), ankle fractures (n=12) and cervical spine injuries (n=7) were the most common injuries; all of which required surgery. Complications included death, spinal cord injuries, compartment syndrome and open fractures. At 6 months post injury, more than half (52%) of the patients had not achieved a good recovery, 32% had some form of persistent disability, 14% did not get back to work and overall physical health for the cohort was well below population norms for the SF-12. CONCLUSION: Adult trampoline-related injuries have increased in the last few years in this cohort identified through VOTOR. Lower limb and spinal injuries are most prevalent. Public awareness and education are important to reduce the risk for people participating in this activity.

Incidence of acute kidney injury following total joint arthroplasty: a retrospective review by RIFLE criteria.

BACKGROUND: Total joint arthroplasty (TJA) is a common procedure with demand for arthroplasties expected to increase exponentially. Incidence of acute kidney injury (AKI) following TJA is reportedly low, with most studies finding an incidence of <2%, increasing to 9% when emergency orthopaedic patients are included. METHODS: Retrospective medical record review of consecutive primary, elective TJA procedures was undertaken at a large tertiary hospital (Alfred). Demographic, peri-operative and post-operative data were recorded. Factors associated with AKI (based on RIFLE criteria) were determined using multiple logistic regression. RESULTS: Between January 2011 and June 2013, 425 patients underwent TJA; 252 total knee replacements (TKR) and 173 total hip replacements (THR). Sixty-seven patients (14.8%) developed AKI, including 51 TKR. Factors associated with AKI (adjusting for known confounders) include increasing body mass index [adjusted odds ratio (AOR) 1.14; 95% CI: 1.07, 1.21], older age (AOR 1.07; 95% CI 1.02, 1.13) and lower pre-operative glomerular filtration rate (AOR 0.97; 95% CI 0.96, 0.99) and taking angiotensin-converting enzyme inhibitors (AOR 2.70; 95% CI 1.12, 6.48) and angiotensin-II receptor blockers (AOR 2.64; 95% CI 1.18, 5.93). In most patients, AKI resolved by discharge, however, only 62% of patients had renal function tests after discharge. CONCLUSIONS: This study showed a rate of AKI of nearly 15% in our TJA population, substantially higher than previously reported. Given that AKI and long-term complications are associated, prospective research is needed to further understand the associated factors and predict those at risk of AKI. There may be opportunities to maximize the pre-operative medical management and mitigate risk.

An intensive physiotherapy program improves mobility for trauma patients.

BACKGROUND: Physiotherapy is integral to modern trauma care. Early physiotherapy and mobility have been shown to improve outcomes in patients with isolated injuries; however, the optimal intensity of physiotherapy in the multitrauma patient population has not yet been examined. The primary aim of this study was to determine whether an intensive physiotherapy program resulted in improved inpatient mobility. METHODS: We conducted a single-center prospective randomized controlled study of 90 consecutive patients admitted to the Alfred Hospital (a Level 1 trauma center) in Australia between October 2011 and June 2012 who could participate in ward-based physiotherapy. Participants were allocated to either usual care (daily physiotherapy treatment, approximately 30 minutes) or intensive physiotherapy (usual care plus two additional 30-minute treatments each day). The primary outcome measure was the modified Iowa Level of Assistance (mILOA) score, collected by a blinded assessor at Days 3 and 5 (or earlier if discharged). Secondary measures included physical readiness for discharge, hospital and rehabilitation length of stay, a patient confidence and satisfaction scale, and quality of life at 6 months. RESULTS: Groups were comparable at baseline. Participants in the intensive physiotherapy group achieved significantly improved mILOA scores on Day 3 (median, 7 points compared with 10 points; p = 0.02) and Day 5 (median, 7.5 points compared with 16 points; p = 0.04) and were more satisfied with their care (p = 0.01). There was no difference between groups in time to physical readiness, discharge destination, length of stay, or quality-of-life measures. CONCLUSION: Intensive physiotherapy resulted in improved mobility in trauma inpatients. Further studies are required to determine if specific groups benefit more from intensive physiotherapy and if this translates to long-term improvements in outcomes. LEVEL OF EVIDENCE: Therapeutic study, level 1.

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

INTRODUCTION: Bed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary. AIM: The aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS). METHOD: A total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010. INTERVENTION: The strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery). OUTCOME MEASURES: Data collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10-14 days, opioid use and re-admission rate. RESULTS: Groups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55 h compared with 71 h in the control group (p<0.0001). Opioid use for the control group was an average of 90 mg morphine equivalent in the first 24 h post surgery compared with 67 mg morphine equivalent for the early mobilisation group (p=0.32). CONCLUSION: This study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.

No rest for the wounded: early ambulation after hip surgery accelerates recovery.

BACKGROUND: Level 3 evidence-based guidelines recommend first walk after hip fracture surgery within 48 h. Early mobilization is resource and effort intensive and needs rigorous investigation to justify implementation. This study uses a prospective randomized method to investigate the effect of early ambulation (EA) after hip fracture surgery on patient and hospital outcomes. METHODS: Sixty patients (41 women and 19 men; mean age 79.4 years) admitted between March 2004 through December 2004 to The Alfred Hospital, Melbourne, for surgical management of a hip fracture were studied. Randomization was either EA (first walk postoperative day 1 or 2) or delayed ambulation (DA) (first walk postoperative day 3 or 4). Functional levels on day 7 post-surgery, acute hospital length of stay and destination at discharge were compared. RESULTS: At 1 week post-surgery, patients in the EA group walked further than those in the DA group (P = 0.03) and required less assistance to transfer (P = 0.009) and negotiate a step (P = 0.23). Patients in the EA group were more likely to be discharged directly home from the acute care than those in the DA group (26.3 compared with 2.4%) and less likely to need high-level care (36.8 compared with 56%). A failed early ambulation subgroup had significantly more postoperative cardiovascular instability and worse results for all outcome measures. CONCLUSION: EA after hip fracture surgery accelerates functional recovery and is associated with more discharges directly home and less to high-level care.