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Aims A proximal femur fracture (PFF) is a common orthopaedic presentation, with an incidence of over 25,000 cases reported in the Australian and New Zealand Hip Fracture Registry (ANZHFR) in 2018. Hip fractures are known to have high mortality. The purpose of this study was to determine the utility of the Clinical Frailty Scale (CFS) in predicting 30-day and one-year mortality after a PFF in older patients. Methods A retrospective review of all fragility hip fractures who met the inclusion/exclusion criteria of the ANZHFR between 2017 and 2018 was undertaken at a single large volume tertiary hospital. There were 509 patients included in the study with one-year follow-up obtained in 502 cases. The CFS was applied retrospectively to patients according to their documented pre-morbid function and patients were stratified into five groups according to their frailty score. The groups were compared using t-test, analysis of variance (ANOVA), and the chi-squared test. The discriminative ability of the CFS to predict mortality was then compared with American Society of Anaesthesiologists (ASA) classification and the patient’s chronological age. Results A total of 38 patients were deceased at 30 days and 135 patients at one year. The 30-day mortality rate increased from 1.3% (CFS 1 to 3; 1/80) to 14.6% (CFS ≥ 7; 22/151), and the one-year mortality increased from 3.8% (CFS 1 to 3; 3/80) to 41.7% (CFS ≥ 7; 63/151). The CFS was demonstrated superior discriminative ability in predicting mortality after PFF (area under the curve (AUC) 0.699; 95% confidence interval (CI) 0.651 to 0.747) when compared with the ASA (AUC 0.634; 95% CI 0.576 to 0.691) and chronological age groups (AUC 0.585; 95% CI 0.523 to 0.648). Conclusion The CFS demonstrated utility in predicting mortality after PFF fracture. The CFS can be easily performed by non-geriatricians and may help to reduce age related bias influencing surgical decision making. Cite this article: Bone Joint Open 2020;1-8:443–449.

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BackgroundHip fractures are a common problem and corrective surgery is recommended within 24hrs. However, most perioperative direct oral anticoagulant (DOAC) guidelines suggest a washout period of 48 hours before major surgery.There is limited data on utility of drug levels. ObjectiveTo investigate the effect of DOAC therapy on time to surgery and patient outcomes, and to explore the impact of different pre-operative protocols on surgical delay. MethodsA multi-centre, retrospective analysis of all adult patients that presented with acute hip fracture at three tertiary hospitals in Perth, Western Australia was performed. Data was collated from the West Australian hip fracture registry and electronic records. Time to theatre, DOAC levels, bleeding and transfusion rates were compared between sites. ResultsOf 1240 hip fracture patients 145 (11.8%) were on anticoagulation, with more patients taking a DOAC than warfarin. The time to surgery was significantly longer for those on a DOAC compared to those on warfarin (P = 0.003). There was no difference in bleeding, transfusion requirement or 30-day mortality in patients taking a DOAC compared to those on warfarin. 58 patients (70.7%) had a DOAC level prior to surgery. Of 25 patients who had a level performed within 12 hours of presentation 13 (52%) had result of ≤50ng/mL. Outcomes were similar between sites. ConclusionThis article is protected by copyright. All rights reserved.People on DOAC treatment had a significant delay before corrective surgery compared to those on warfarin. The frequent finding of early DOAC levels <50ng/mL suggests this delay may be unnecessary in a significant proportion of patients.

This study evaluated hip fracture transfer times, delays to definitive surgery affecting mortality and the negative impact of patient transfer on outcomes.