2021 John Charnley Award: A protocol-based strategy when using hemiarthroplasty or total hip arthroplasty for femoral neck fractures decreases mortality, length of stay, and complications

Abstract

Aims While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. Methods In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. Results A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). Conclusion The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3–8.

Modifiable and non-modifiable risk factors in hip fracture mortality in Norway, 2014 to 2018

“…Possible explanations might be the selection of frail and high-risk patients to be treated by experienced surgeons, and the fact that patients treated with arthroplasty are preferentially operated on by more experienced surgeons and wait longer than other patients. 12 Orthogeriatric assessment is recommended to improve functional outcomes, 14 and has been shown to reduce mortality in FnFs receiving arthroplasty by roberts et al 22 in this study, orthogeriatric services were associated with lower mortality, all fracture types included. in a systematic review, abrahamsen et al 1 found that increased mortality might be elevated for years after injury, particularly for males.…”

“…Orthogeriatric assessment is recommended to improve functional outcomes, 14 and has been shown to reduce mortality in FNFs receiving arthroplasty by Roberts et al 22 In this study, orthogeriatric services were associated with lower mortality, all fracture types included.…”

Improved outcomes and reduced medical costs through multidisciplinary co-management protocol for geriatric proximal femur fractures: a one-year retrospective study

“…Finally, a retrospective study has reviewed the effectiveness of standardized interdisciplinary hip fracture protocol on, specifically, patients with femoral neck fractures treated with hemiarthroplasties (HA) or total hip arthroplasties (THA). A significantly decreased rate of major complication, decreased median length of hospital stay, decreased 1-year mortality, and increased rate of discharge home were observed amongst patients treated after the introduction of the protocol [ 36 ]. Despite the fact that subgroup analysis with accordance to fracture patterns or types of operated surgeries was not performed in this study, the protocol-driven treatment pathways might provide different extents of benefit to patient associated with certain fracture pattern or surgical intervention.…”

Effectiveness of Perioperative Comprehensive Evaluation of Hip Fracture in the Elderly

“…CGA is not only for the disease itself but also for the overall situation of elderly patients [ 24 ] and not only pays attention to physical conditions but also pays more attention to cognitive and psychological conditions [ 25 , 26 ]. At present, the perioperative intervention effect of CGA on elderly hip fracture patients is not consistent, and there are very few studies on CGA in China [ 27 ]. For hip fracture patients over 65 years old, the implementation of CGA can reduce the mortality rate compared with the conventional group.…”