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Introduction:The use of a multidisciplinary clinical pathway (MCP) for patients with hip fracture tends to be more effective than usual care (UC). The aim of this study was to evaluate the effects of an MCP approach on time to surgery, length of stay, postoperative complications, and 30-day mortality, compared to UC.Materials and Methods:This multicenter retrospective cohort study included patients aged 50 years or older with a proximal hip fracture who underwent surgery in one of the 6 hospitals in the Limburg trauma region of the Netherlands in 2012. Data such as demographics, process outcome measures, and clinical outcome were collected.Results:This study included a total of 1193 patients (665 and 528 patients in the MCP and UC groups, respectively). There were no differences in patient demographics present. Time to surgery was significantly shorter in the MCP compared to the UC group (19.2 vs 24.4 hours, P < .01). The mean length of stay was 10 versus 12 days (P < .01). In the MCP group, significantly lower rates of postoperative complications were observed and significantly more patients were institutionalized than in the UC group. Mortality within 30 days after admission was comparable between the groups (overall mortality 6%).Conclusion:An MCP approach is associated with reduced time to surgery, postoperative complications, and length of stay, without a significant difference in 30-day mortality. The institutionalization rate was significantly higher in the MCP group.

IntroductionA Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime.Materials and methodsThis retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected.ResultsThis cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively.ConclusionPWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.

Background The incidence of hip fractures is increasing. Elderly patients with a hip fracture frequently present with comorbidities, which are associated with higher mortality rates. Clinical studies regarding long-term functional outcome and mortality in hip fractures are rare. The aim of this study was to analyse the functional outcome and the mortality rate after a follow-up of 5 years in elderly patients with a hip fracture. Materials and Methods This combined retrospective and cross-sectional study included patients aged 65 years or older with a low energy hip fracture who underwent surgery in the Maastricht University Medical Center+, the Netherlands. Data such as demographics and mortality rates were retrospectively collected and functional outcome (i.e. mobility, pain, housing conditions and quality of life) was assessed by a questionnaire. Results Two hundred and sixteen patients were included in this study (mean age 82.2, SD ± 7.5). No significant differences were found in pain before hip fracture and after 1-year and 5-year follow-ups. Long-term functional outcome deteriorated after a hip fracture, with a significant increase in the use of walking aids ( p < 0.001), a significant decrease of patients living in a private home ( p < 0.001), and a low physical quality of life (SF-12 PCS = 27.1). The mortality incidences after 30-day, 1-year and 5-year follow-ups were 7.9%, 37.0% and 69.4%, respectively. Conclusion Long-term functional outcome in elderly patients with hip fractures significantly deteriorated, with an increased dependency for mobility and housing conditions and a decreased physical quality of life. In addition, hip fractures are associated with high mortality rates at the 5-year follow-up. Level of evidence Level III, a retrospective cohort study.

Introduction: There is an increase in incidence of hip fractures in the ageing population. The implementation of multidisciplinary clinical pathways (MCP) has proven to be effective in improving the care for these frail patients, and MCP tends to be more effective than usual care (UC). The aim of this study was to analyze potential differences in patient-reported outcome among elderly patients with hip fractures who followed MCP versus those who followed UC. Materials and Methods: This retrospective cohort study included patients aged 65 years or older with a low-energy hip fracture, who underwent surgery in the Maastricht University Medical Center, Maastricht, the Netherlands. Two cohorts were analyzed; the first one had patients who underwent UC in 2012 and the second one contained patients who followed MCP in 2015. Collected data regarded demographics, patient-reported outcomes (Short Form 12 [SF-12] and the Numeric Rating Scale [NRS] to measure pain), and patient outcome. Results: This cohort study included 398 patients, 182 of them were included in the MCP group and 216 were in the UC group. No differences in gender, age, or American Society of Anesthesiologists classification were found between the groups. No significant differences were found in SF-12 and the NRS data between the MCP group and UC group. In the MCP group, significantly lower rates of postoperative complications were found than in the UC group, but mortality within 30 days and one year after the hip fracture was similar in both groups. Discussion: Although the effects of hip fractures in the elderly on patient-reported outcome, pain and quality of life have been addressed in several recent studies, the effects of MCP on long-term outcome was unclear. Conclusion: A multidisciplinary clinical pathway approach for elderly patients with a hip fracture is associated with a reduced time to surgery and reduced postoperative complications, while no differences were found in quality of life, pain, or mortality.

IntroductionThe standard aftercare treatment (according to the AO guideline) for surgically treated trauma patients with fractures of the tibial plateau is non-weight bearing or partial weight bearing for 10–12 weeks. The purpose of this study was to investigate the current state of practice among orthopaedic surgeons and trauma surgeons in choosing the criteria and the time period of restricted weight bearing after surgically treated tibial plateau fractures.Materials and methodsA web-based survey was distributed among members of the Dutch Trauma Society and Dutch Orthopaedic Society to identify the most commonly applied protocols in terms of the post-operative initiation and level of weight bearing in patients with tibial plateau fractures.ResultsOne hundred and eleven surgeons responded to the survey. 72.1% of the respondents recommended starting weight bearing earlier than the 12 weeks recommended by the AO guideline; 11.7% recommended starting weight bearing immediately, 4.5% after 2 weeks and 55.9% after 6 weeks. Moreover, 88.7% of the respondents reported deviating from their own local protocol. There is little consensus about the definition of 100% weight bearing and how to build up weight bearing over time.ConclusionThis study demonstrates that consensus about the weight bearing aftercare for tibial plateau fractures are limited. A large majority of surgeons do not follow the AO guideline or their own local protocol. More transparent criteria and predictors are needed to design optimal weight-bearing regimes for the aftercare of tibial plateau fractures.

BackgroundThe standard aftercare treatment in surgically treated trauma patients with fractures around or in a joint, known as (peri)- or intra-articular fractures of the lower extremities, is either non-weight bearing or partial weight bearing. We have developed an early permissive weight bearing post-surgery rehabilitation protocol in surgically treated patients with fractures of the lower extremities. In this proposal we want to compare our early permissive weight bearing protocol to the existing current non-weight bearing guidelines in a prospective comparative cohort study.Methods/designThe study is a prospective multicenter comparative cohort study in which two rehabilitation aftercare treatments will be contrasted, i.e. permissive weight bearing and non-weight bearing according to the AO-guideline. The study population consists of patients with a surgically treated fracture of the pelvis/acetabulum or a surgically treated (peri)- or intra-articular fracture of the lower extremities. The inclusion period is 12 months. The duration of follow up is 6 months, with measurements taken at baseline, 2,6,12 and 26 weeks post-surgery.Primary outcome measure: ADL with Lower Extremity Functional Scale. Outcome variables for compliance, as measured with an insole pressure measurement system, encompass peak load and step duration.DiscussionThis study will investigate the (cost-) effectiveness of a permissive weight bearing aftercare protocol. The results will provide evidence whether a permissive weight bearing protocol is more effective than the current non-weight bearing protocol.Trial registrationThe study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01–09-2016.

Aftercare in surgically treated trauma patients with fractures of the pelvis and lower extremities has remained largely unchanged during the past 60 years. To optimize rapid clinical recovery and the restoration of function and functionality, permissive weight-bearing has been designed as a new aftercare mobilization regime, within the upper boundary of the therapeutic bandwidth, yet safe enough to avoid overloading. The aim of the present paper is to describe a comprehensive protocol for permissive weight-bearing during allied health therapy and to report on both the time to full weight-bearing and the number of complications in patients with surgically treated fractures of the pelvis and lower extremities who undergo permissive weight-bearing. Objective: To optimize rapid clinical recovery and restoration of function and functionality, permissive weight-bearing has been designed as a new aftercare mobilization regimen, within the upper boundary of the therapeutic bandwidth, yet safe enough to avoid overloading. The aim of the present paper is to describe a comprehensive protocol for permissive weight-bearing during allied health therapy and to report on the time to full weight-bearing, as well as the number of complications, in patients with surgically treated fractures of the pelvis and lower extremities undergoing permissive weight-bearing. Patients and methods: This study included surgically treated trauma patients with (peri)-or intra-articular fractures of the pelvis and lower extremities. A standardized permissive weight-bearing protocol was used for all patients. Time to full weight-bearing and number of complications were recorded. Results: This study included 150 patients, 69% male, with a median age of 48 years (interquartile range (IQR) 33.0, 57.0). The median time to full weight bearing was 12.0 weeks (IQR 6.8, 19.2). The complication rate during rehabilitation was 10%. Conclusion: The permissive weight-bearing protocol, as described, might be beneficial and has potential to be implemented in trauma patients with surgically treated (peri)-or intra-articular fractures of the pelvis and lower extremities.