Inter-departmental variation in surgical treatment of proximal femoral fractures: A nationwide observational cohort study

Abstract

Background and purpose Hip fractures should be treated based on the best available evidence and cost-effectively to optimize the outcome for this large group of frail patients. This study examined nationwide variation in surgical methods used for hip fractures. Methods In this cohort study 46,243 patients ≥65 years with a trochanteric hip fracture (THF) or a femoral neck fracture (FNF) registered in the Swedish Fracture Register (SFR) between 1 January 2016 and 31 December 2020 were included. Fractures were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification system. The choice of surgical methods was assessed for each fracture type to compare national variation. Results 21,312 THFs and 24,072 FNFs (67% women) with a mean age of 83 years (SD 8) were surgically treated. In the treatment of two-fragment THFs (AO/OTA A1) departments ranged from using 90% short intramedullary nails to 98% sliding hip screws. Treating displaced FNFs (AO/OTA B3), the proportion of hemiarthroplasty ranged from 9 to 90%, and internal fixation between 0.6 to 21%, depending on the department. Interpretation A mature national fracture register permits the monitoring of treatment provided and thus serves as an important aid in assessing compliance with guidelines. The large inter-departmental variation in the surgical management of hip fractures in Sweden appears unwarranted based on the current evidence, indicating a need for updated national guidelines. Further research will have to clarify the impact of this variation on mortality and re-operation rates.

Basicervical femoral neck fractures: an observational study derived from the Swedish Fracture Register

“…With a fracture line at the base of the femoral neck, the relationship between the joint capsule with its associated blood supply and the proximal fragment is unclear. Optimizing treatment of bFNFs could involve addressing technical (i.e., fracture reduction, implant choices, and implant positioning) and biological factors (i.e., whether the bFNF is an intra- or extracapsular fracture or both), as well as individual/institutional algorithms or treatment traditions [ 25 , 26 ].…”

Reoperation-free survival after hip screws or hip arthroplasty for undisplaced femoral neck fractures in the elderly

“…The routine surgical procedure for undisplaced femoral neck fractures (uFNFs) in Sweden, regardless of the patient's age, is internal fixation (IF) with two to three screws or hook pins. 1 In older patients, reoperation rates ranging between 8% and 27% after IF of uFNFs have been reported. [2][3][4][5] Advanced age has been described as a risk factor for healing complications in uFNFs treated with IF, but less for primary arthroplasty.…”