A new algorithm for hip fracture surgery

Figures & data

The algorithm for hip fracture surgery.

Table 1. Data for the 2,000 patients who were operated either before or after implementation of the algorithm

	Before algorithm		After algorithm
	n	%	n	%	p-value
No. of patients	1,000		1,000
Age (years) ^a	83 (76–89)		83 (74–89)		0.7
Female gender	749		742		0.7
ASA score III–IV	517		291		< 0.001
Prefracture NMS 0–5	530		434		< 0.001
Low cognitive function	297		287		0.6
Dead within 1 year ^b	307		306		0.6
Reoperations within 1 year	180	100	124	100	< 0.001
Hematoma/Bleeding	3	2	3	2
Infection	26	15	11	9
Dislocation of prosthesis	20	11	21	17
Loosening of prosthesis	6	3	2	2
Periprosthetic fracture	25	14	12	10
Avascular necrosis of femoral head	8	4	5	4
Nonunion	51	28	37	29
Cutout of implant into hip joint	23	13	15	12
Fracture around the implant	8	5	9	7
Distal locking screw position	2	1	2	2
Subsequent osteoarthritis	2	1	1	1
Implant removal due to pain/discomfort	6	3	6	5

Values are presented as number of patients and were analyzed using the chi-square test, except for:

^a Age, presented as median (interquartile range) and analyzed using Mann-Whitney test.

^b Dead within 1-year, analyzed using Kaplan-Meier test.

ASA: American Society of Anaesthesiologists; NMS: New Mobility score.

Table 2. Relationship between reoperation within 1 year postoperatively and patient characteristics in the 2,000 patients who were operated before or after implementation of the algorithm

		Multiple Cox regression analysis
	n (%)	HR	(95% CI)	p-value
Age (years) ^a	83 (75–89)	1.0	(1.0–1.0)	0.002
Female gender	1,491 (75)	1.2	(0.9–1.5)	0.3
ASA score III–IV	808 (40)	1.2	(0.9–1.5)	0.2
Prefracture NMS 0–5	964 (48)	0.8	(0.6–1.0)	0.08
Low cognitive function	584 (29)	0.8	(0.6–1.1)	0.2
Surgical algorithm	1,000 (50)	0.7	(0.5–0.8)	< 0.001

^a Age presented as median (interquartile range).

HR: hazard ratio; ASA: American Society of Anaesthesiologists; NMS: New Mobility score.

Table 3. Fracture type, operation type, and rate of reoperation for the 2,000 patients who were operated before or after implementation of the algorithm

	Before algorithm		After algorithm
		Reop.		Reop.
Fracture type		rate		rate
Type of operation	n	(%)	n	(%)	p-value
Femoral neck fractures	467	24	482	18	0.02
Undisplaced	88	17	79	13	0.3
Parallel implants ^a	75		74
Prosthesis	9		5
Other	4		–
Displaced (Age < 70 years)	37	51	61	27	0.5
Parallel implants ^a	25		37
Prosthesis ^b	8		23
Other	4		1
Displaced (Age ≥ 70 years)	329	22	328	13	0.005
Prosthesis ^a	288		316
Femoral head removal ^c	2		3
Parallel implants	38		7
Other	1		2
Vertical	13	39	14	43	0.7
DHS (2 holes) ^a	9		11
DHS (other types)	1		1
Parallel implants	3		2
Extracapsular fractures	533	13	518	7	0.002
Basocervical	22	9	21	14	0.7
DHS (2 holes) ^a	13		20
DHS (other types)	7		–
Parallel implants	–		1
Prosthesis	2		–
Stable trochanteric	211	7	144	4	0.3
DHS (4 holes) ^a	204		136
DHS (other types)	4		–
IMHS	3		8
Unstable trochanteric	300	17	353	8	< 0.001
IMHS ^a	112		337
DHS (4 holes)	156		13
DHS (other types)	32		–
Other implants	–		3
All hip fractures	1,000	18	1,000	12	< 0.001
Level of surgeon
Unsupervised junior registrar	192	20	105	11	0.03
Supervised junior registrar	287	16	398	10	0.02
Senior registrar or consultant	521	18	497	15	0.08

^a Operation type dictated by the algorithm.

^b Prosthesis is dictated if not fully reducible on the traction table.

^c Femoral head removal is dictated if bedridden.

Rates of reoperation were analyzed using univariate Cox regression analysis.