BACKGROUND: The objectives of the study were to: (1) evaluate satisfaction with the new 2023 National Institute of Health and Care Excellence (NICE) criteria for selecting total hip arthroplasty (THA) over hemiarthroplasty and surgical recommendations for treatment of displaced intracapsular hip fractures; (2) describe why THA is performed when NICE criteria are not met; and (3) determine whether satisfaction with these guidelines is associated with improved outcomes.
METHODS: A retrospective chart review of patients who had a displaced intracapsular hip fracture treated with THA at a single tertiary academic center between 2010 and 2022 was performed. Preoperative patient characteristics were reviewed to determine if the indication for THA met NICE criteria. Operative details, perioperative complications, reoperation, and revision arthroplasty within 12 months of surgery were recorded.
RESULTS: Data from 196 patients (63% women; age 67 ± 10 years) were used. There were 161 THAs (82.1%) that satisfied NICE criteria. The 2 most common reasons for performing a THA when NICE criteria were not met (n = 35) included preoperative radiographic osteoarthritis (Tönnis grade ≥ 2; 48.6%) and decreased patient age (< 65 years; 31.5%). Satisfaction with the NICE criteria was associated with fewer perioperative complications (0.6 versus 37.1%; P < .001), reoperations (0.6 versus 31.4%; P < .001), and revisions (0.6 versus 28.6%; P < .001). The most common reason for revision was periprosthetic fracture, possibly secondary to the use of uncemented femoral stems (171 of 196, 87.2%).
CONCLUSIONS: Satisfaction with the new NICE criteria is associated with improved perioperative outcomes. Further studies are necessary to determine if preexisting hip osteoarthritis and younger age merit consideration in patient selection.

暂无摘要。

Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision-making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient\'s treatment.

OBJECTIVE: Patients with hip fractures frequently present at the emergency department (ED). Despite high pain scores, prehospital pain management is often inadequate and insufficient. In the Netherlands, the emergency medical services (EMS) exhibit a high level of training, supported by a comprehensive pain treatment protocol. This study aimed to assess adherence to the protocol and hypothesized that prehospital pain management in hip fracture patients was both sufficient and adequate.
METHODS: This was a retrospective observational cohort study of patients with suspected hip fractures. The median differences in numerical rating scale (NRS) pain scores between the initial score in the ambulance and upon arrival at the ED were compared. Furthermore, adherence to the ambulance pain protocol was studied.
RESULTS: From September 2016 to March 2021, 436 ambulance-transported hip fracture patients were included, of whom 81% received analgesics by EMS. The median initial pain score measured by EMS was 8; this number decreased to 5 at ED presentation, a significant decrease (ρ < 0.001). In case a prehospital NRS pain score was assessed, 66.5% of the patients were treated according to the protocol. In 80% of patients, the protocol was not followed correctly, primarily due to missing NRS pain scores.
CONCLUSIONS: In suspected hip fracture patients, initial prehospital pain scores were high and most patients received analgesics from EMS. This resulted in a significant decrease in pain. In nearly 67% of patients in whom an NRS pain score was assessed in the prehospital phase, pain management was according to protocol. However, in 80% of the total population the pain protocol was not adhered to, mainly due to missing NRS pain scores.

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population.

UNASSIGNED: Hip fracture is common in older people - with prevalence even higher for people with dementia. Research often excludes people with dementia - especially those in the more advanced stages. Therefore, the most appropriate interventions remain unknown. The main aim of this study was to gain consensus about the core considerations needed to deliver a physical intervention for people with advanced dementia who fracture their hip. Materials and Methods: An expert consensus process was undertaken, using Nominal Group Technique, to explore the key considerations when delivering rehabilitation. Data collection was undertaken in January 2023 and involved an online group discussion followed by voting and off-line rating. Qualitative content analysis and quantitative analysis of consensus scoring was undertaken. An international group of seven highly specialised physiotherapists took part.
UNASSIGNED: 59 statements were agreed following the process. Content analysis was used to categorise these statements according to the International Classification of Functioning, Disability and Health. Although consensus levels were high, there was disagreement in several areas.
UNASSIGNED: The statements provide an overarching understanding of the multidisciplinary expertise that is needed to effectively deliver rehabilitation interventions to this population. People with dementia require highly skilled and trained professionals, providing holistic and person-centred approaches to deliver rehabilitation interventions.IMPLICATIONS FOR REHABILITATIONThe expert consensus provides an overarching understanding of the multidisciplinary expertise that is needed to effectively deliver rehabilitation interventions to this population.Physiotherapy - or other interventions - cannot be used in isolation.People with dementia require highly skilled and trained professionals, providing holistic and person-centred approaches to deliver rehabilitation interventions.While our focus was on hip fracture, we suggest these statements can be used for people with advanced dementia with a variety of other conditions.

A hip fracture is a major adverse event for older individuals that has extremely high rates of mortality and morbidity, specifically functional decline. Thus, effective post-hip fracture rehabilitation is crucial to enable patients to regain function and improve their quality of life. Most post-hip fracture rehabilitation programs focus only on physical functioning, but rehabilitation goals related to the quality of life, social participation, and environmental issues are also crucial considerations. This study aimed to develop a core set of considerations based on the International Classification of Functioning, Disability, and Health (ICF) for use as a reference in designing comprehensive rehabilitation programs for patients with hip fractures. For this purpose, we recruited 20 experts from related fields working at a university hospital to complete a three-round Delphi-based questionnaire. Before beginning this process, a literature review related to ICF category selection was conducted. Next, a 5-point Likert scale was employed to rate the importance of each proposed category, and Spearman\'s rank correlation coefficient and semi-interquartile range indices were analyzed to rate the consensus status. Categories for the ICF core set of considerations for post-hip-fracture rehabilitation were chosen on the basis of a high level of consensus and a mean score of ≥4.5 in the third Delphi-based questionnaire round. After selection, the ICF core set comprised 34 categories, namely 15 for bodily functions, 5 for bodily structures, 13 for activities and participation, and 1 for environmental factors. The proposed post-hip-fracture rehabilitation ICF core set can serve as a reference for developing effective rehabilitation strategies and goal setting by interdisciplinary teams. However, further feasibility evaluation is recommended for individualized rehabilitation program design.

We conducted a systematic review and meta-analysis of contemporary RCTs to determine the clinical effectiveness of spinal vs general anaesthesia (SA vs GA) in patients undergoing hip fracture surgery using a consensus-based core outcome set, and outcomes defined as important by patient and public involvement (PPI) initiatives.
RCTs comparing any of the core outcomes (mortality, time from injury to surgery, acute coronary syndrome, hypotension, acute kidney injury, delirium, pneumonia, orthogeriatric input, being out of bed at day 1 postoperatively, and pain) or PPI-defined outcomes (return to preoperative residence, quality of life, and mobility status) between SA and GA were identified from MEDLINE, Embase, Cochrane Library, and Web of Science (2000 to February 2022). Pooled relative risks (RRs) and mean differences (95% confidence intervals [CIs]) were estimated.
There was no significant difference in the risk of delirium comparing SA vs GA (RR=1.07; 95% CI, 0.90-1.29). Comparing SA vs GA, the RR for mortality was 0.56 (95% CI, 0.22-1.44) in-hospital, 1.07 (95% CI, 0.52-2.23) at 30 days, and 1.08 (95% CI, 0.55-2.12) at 90 days. Spinal anaesthesia reduced the risk of acute kidney injury compared with GA: RR=0.59 (95% CI, 0.39-0.89). There were no significant differences in the risk of other outcomes. Few studies reported PPI-defined outcomes, with most studies reporting on one to three core outcomes.
Except for acute kidney injury, there were no differences between SA and GA in hip fracture surgery when using a consensus-based core outcome set and patient and public involvement-defined outcomes. Most studies reported limited outcomes from the core outcome set, and few reported outcomes important to patients, which should be considered when designing future RCTs.
CRD42021275206.

OBJECTIVE: Two medical specialties, general surgery and orthopaedic surgery, with different training programs but matching trauma certification requirements, provide hip fracture surgery in the Netherlands. This study analyses treatment preferences and guideline adherence of Dutch surgeons with different surgical backgrounds.
METHODS: All hip fracture patients registered in the Dutch Hip Fracture Audit in 2018 and 2019 were included in this retrospective study. Four types of surgeons were distinguished: trauma-certified general surgeons (ST+), non-trauma certified general surgeons (ST-), trauma-certified orthopaedic surgeons (OT+) and non-trauma certified orthopaedic surgeons (OT-). Differences in patient characteristics, and practice variation in treatment choices and guideline adherence per fracture type were analysed using descriptive statistics.
RESULTS: 28,656 patients were included; 16,367 (57.1%) treated by ST+, 1,371 (4.8%) by ST-, 4,692 (16.4%) by OT+ and 6,226 (21.7%) by OT-. Few clinically relevant differences in patient characteristics and hospital processes were found between all surgeon groups. Displaced FNF were the most commonly treated fracture type for all types of surgeons. Both OT+ and OT- operated mostly (displaced) FNFs, while the fracture types treated by ST+ and ST- were more heterogeneous. For all fracture types, the orthopaedic surgeons performed THA and HA more often than general surgeons, while general surgeons more often placed SHS and IMN for specific fracture types. Guideline adherence was on average 68.4% and differed significantly per surgeon type (68.7% by ST+, 65.2% by ST-, 74.4% by OT+ and 63.6% by OT- (p<0.01)), as well as per fracture type: >90% treatment according to the guideline for trochanteric AO-31A2 and A3 fractures, 18.8% for AO-31A1 fractures and 51.7% guideline adherence for undisplaced FNF. Guideline adherence for displaced FNF varied depending on patient characteristics.
CONCLUSIONS: In the Netherlands, different surgical specialists treat different types of hip fractures and have different preferences concerning implants for hip fracture surgery in comparable patients. Guideline adherence of trauma- and non-trauma certified orthopaedics and general surgeons differs significantly. Reduction of practice variation should be strived for in order to improve hip fracture care.

Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF).
A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care.
In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care.
We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.