National Hip Fracture Database Research Articles

Following hip fracture, hospital organisational factors associated with prescription of anti-osteoporosis medication on discharge, to address imminent refracture risk: a record-linkage study.

Patients who sustain a hip fracture are known to be at imminent refracture risk. Their complex multidisciplinary rehabilitation needs to include falls prevention and anti-osteoporosis medication (AOM) to prevent such fractures. This study aimed to determine which hospital-level organisational factors predict prescription of post-hip fracture AOM, and refracture risk. A cohort of 178 757 patients aged ≥60years who sustained a hip fracture in England and Wales (2016-19) was examined and followed for 1year. Patient-level hospital admission datasets from 172 hospitals, the National Hip Fracture Database, and mortality data were linked to 71 metrics extracted from 18 hospital-level organisational reports. Multilevel models determined organisational factors, independent of patient case-mix, associated with (i) AOM prescription, (ii) refracture (by ICD10 coding). Patients were mean (SD) 82.7 (8.6) years old, 71% female, with 18% admitted from care homes. Overall, 101 735 (57%) were prescribed AOM during admission; while 50 354 (28%) died during 1-year follow-up, 12 240 (7%) refractured. Twelve organisational factors were associated with AOM prescription, e.g., orthogeriatrician-led care compared to traditional care models (OR 4.65 [95%CI: 2.25-9.59]); AOM was 9% (95%CI: 6%-13%) more likely to be prescribed in hospitals providing routine bone health assessment to all patients. Refracture occurred at median 126days (IQR 59-234). Eight organisational factors were associated with refracture risk; hospitals providing orthogeriatrician assessment to all patients within 72-hours of admission had an 18% (95%CI: 2-31%) lower refracture risk, weekend physiotherapy provision an 8% (95%CI: 3-14%) lower risk, and where occupational therapists attended clinical governance meetings, a 7% (95%CI: 2-12%) lower risk. Delays initiating post-discharge community rehabilitation were associated with a 15% (95%CI: 3-29%) greater refracture risk. These novel, national findings highlight the importance of orthogeriatrician, physiotherapist and occupational therapist involvement in secondary fracture prevention post hip fracture; notably fracture risk reductions were seen within 12months of hip fracture.

682 Impact of Regionalisation of Major Trauma Services on Hip Fracture Care in England: A Comparative Study

Abstract Aim Following the establishment of Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may negatively impact their care of hip fracture patients. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs). Method National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs). Results 487,089 patients were included from 167 hospitals (23 MTCs, 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p<0.001) and mobilisation by first postoperative day (81.9% vs 79.7%, p<0.001). Fewer patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p<0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p<0.001), and fewer MTC patients were discharged to their original residence (60.4% vs 63.5%, p<0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825). Conclusions This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, with similar mortality rates compared to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients.

Minimizing the Risk of Surgical Site Infection Following Hip Fracture Operation.

Introduction: Hip fractures are the most common serious injury in the elderly, associated with disability, morbidity, and mortality. Surgical site infection (SSI) is a serious post-operative complication. This prospective cohort study outlines how our center made cumulative improvements in SSI incidence rates, reaching a 12-month average of 0.5%. Methods: All patients undergoing hip fracture operation between 2016 and 2021 were included. The primary outcome measure was confirmed SSI, according to the Public Health England definition. Results were compared with the baseline recordings by an independent SSI team in 2013. Demographic data were compared with National Hip Fracture Database records. Peri-operative infection control and wound management tactics introduced between 2014 and 2021 were collated to gain an overview care bundle. Results: Baseline recordings identified a 9.0% SSI rate in a three-month observation period. In our study, 3,138 hip fracture operative cases were completed between October 2016 and December 2021. There were 9 superficial and 32 deep infections identified, yielding an overall infection rate of 1.3%. However, when analyzing the 12-month average, there was consistent decline in SSI from the baseline 9.0% in 2013 to 0.5% in 2021 (p < 0.05). A peri-operative care bundle included pre-operative bleeding risk assessment. Intra-operatively, double preparation and draping is used for arthroplasty. Broad-spectrum antibiotic agents and tranexamic acid are administered. Meticulous hemostasis and watertight wound closure are observed. Anti-coagulated patients received negative pressure dressings. Post-operatively, a dedicated senior lead team provided daily inpatient review of patients, with urgent consultant review of all wound healing concerns. Conclusion: Patients with a hip fracture have numerous risk factors for SSI. A dedicated multi-focal tactic, adopted by a multi-disciplinary department, can yield substantial risk reduction. Each intervention is evidence based and contributes to cumulative improvement. By prioritizing infection prevention, we have minimized the need for complex infection management interventions and achieved an annual saving of £860,000 for our trust.

IMPACT OF REGIONALIZATION OF MAJOR TRAUMA SERVICES ON HIP FRACTURE CARE IN ENGLAND: A COMPARATIVE STUDY

Following the establishment of regional Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may have a detrimental impact on the care of patients with hip fractures in these hospitals. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs).National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, consultant supervision in theatre, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs).A total of 487,089 patients with hip fractures were included from 167 hospitals (23 MTCs and 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p&lt;0.001) and mobilisation out of bed by first postoperative day (81.9% vs 79.7%, p&lt;0.001). A lower proportion of patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p&lt;0.001). However, there was significantly higher consultant surgeon and anaesthetist supervision rates during surgery in MTCs (71.8% vs 61.6%, p&lt;0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p&lt;0.001), and proportionately fewer MTC patients were discharged to their original residence (63.5% vs 60.4%, p&lt;0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825).This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, as their mortality rates are similar to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients.

The burden of periprosthetic femoral fractures in England and Wales: Insights from the first two years of data collection in the National Hip Fracture Database and regional variation in care

IntroductionPeriprosthetic femoral fractures (PPFFs) represent an important healthcare problem, with a rising incidence noted due to an increase in the number of arthroplasty surgeries being performed. There is a current lack of national consensus as to how these complex, often frail patients are managed. AimsOur primary aim was to present the epidemiology of PPFFs in England and Wales over the first two years of data collection by the National Hip Fracture Database (NHFD). Secondary aims included how well the NHFD Key Performance Indicators (KPIs) are met for PPFF patients, whether centres reporting a higher burden of PPFF patients are more likely to meet KPIs compared to lower volume centres, and to also identify if regional variation in care for these patients exist. MethodsPatients aged 60 years or over, admitted to any acute hospital in England or Wales with a PPFF within the period 1st January 2020 to 31st December 2021 were included. Fractures were classified using the Vancouver system. The primary outcome of interest was the incidence of PPFF in England and Wales. Secondary outcomes included i) geographical distribution, ii) pattern of injury, iii) treatment received, iv) KPI performance nationally, v) KPI performance by top 5 highest volume hospitals vs the rest, vi) KPI performance by region and vii) KPI performance compared with native hip fracture patients. ResultsA total of 5,566 PPFFs were reported during our study period. A 31 % increase in cases was seen between 2020 and 2021 (2,405 to 3,161). The South-West of England reported the highest burden of PPFFs (14 % of all cases reported in 2021). Vancouver B subtypes were most common around hip replacements (62 %) and C subtype around knee replacements (55 %). A total of 4,598 patients (82.6 %) underwent operative management. There was regional variation in KPI attainment. When compared to KPI attainment for native hip fractures PPFF care under performed in most regions and domains. High volume PPFF centres were not associated with improved attainment of KPIs. ConclusionWe have described the incidence, nature, and management of PPFF at national and regional levels using routinely collected NHFD data. Both numerically and due to case complexity, PPFF are a considerable challenge to patients and health services alike. This epidemiology is not captured by other existing datasets and increased case contribution to the NHFD is encouraged to improve understanding and enable prioritisation and delivery of further care and research.

Safety and efficacy in the management of older patients with displaced intracapsular hip fractures

The management of the older person with a displaced intracapsular hip fracture is one of the most significant aspects of musculoskeletal trauma. These patients require prompt, integrated pathway delivered care. The care delivered outside of the operating theatre and that performed within, are intertwined. Traditionally, surgeons have focussed predominantly only on the operative elements. In modern trauma care for older people, this focus must broaden. We provide for the first time a comprehensive overview of all elements of care for this important patient group. This brings together pathway elements from the National Hip Fracture Database Key Performance Indicators and NICE guidance alongside a synthesis of all current research output for intracapsular hip fracture.

P078 United Kingdom rates and determinants of romosozumab prescriptions, a need for greater action

Abstract Background/Aims Romosozumab rapidly reduces fracture risk and has been recommended as a first-line option for post-menopausal persons with severe osteoporosis and a recent major fracture from November 2020 (Scotland) and May 2022 (England, Northern Ireland and Wales). Aim: to describe hospital-level romosozumab prescriptions and the determinants across the four nations. Methods Hospital-level romosozumab prescription data were analysed by country. Potential predictors included surrogates of local patient need (the population of women aged 50 years and over), local FLS status (none, partial, full) and, in England and Wales, the number of patient records submitted to the mandatory national audits for Fracture Liaison Service (FLSDB) and National Hip Fracture Database (NHFD) in 2021. Spearman correlations and zero-inflated Poisson models identified independent determinants of: a) any prescription and b) the number of prescriptions or romosozumab. Results 152 sites were included (England-126, N. Ireland-5, Scotland-14, and Wales-7) with 60 full and 28 partial FLSs. 63 sites recorded a least one romosozumab prescription in 2022. The proportion of hospitals with any prescription varied from 20% in Northern Ireland to 64.3% in Scotland. An estimated four million women aged 50+ lived in areas with no romosozumab delivery. No determinants of any prescription were identified. With England as the referent group, the number of prescriptions was greater in Scotland (p = 0.001) and lower in Northern Ireland (p = &amp;lt;0.001). After adjusting for the number of women aged 50 years and over (p = 0.008), a full FLS but not partial FLS predicted the number of prescriptions (Figure). In England and Wales both local NHFD (Rs = 0.19, p = 0.03) and FLSDB records (Rs = 0.25, p = 0.056) predicted the number of local prescriptions. Conclusion Even after inclusion in national guidelines, there is a care gap of at least four million women in the UK. In NHS sites that have started prescribing romosozumab, the patient numbers are significantly below expected rates. A national implementation strategy should be considered for decision makers, healthcare providers and patient groups to minimise the number of subsequent fragility fractures in the FLS setting by increasing the number of sites implementing romosozumab focusing on FLS first and matching local delivery to local population needs. Disclosure M.K. Javaid: Consultancies; MKJ has received honoraria, travel and/or subsistence expenses from: Amgen, Kyowa Kirin Hakin, UCB, Abbvie, Besin Healthcare, Sanofi. Grants/research support; MKJ has received unrestricted research grants Amgen, Kyowa Kirin Hakin, UCB. T. Jones: Corporate appointments; Employee of British and Irish BioPharma SPRL. S. Hepworth: Corporate appointments; Employee UCB BioPharma SPRL.

Comparison of acute outcomes from elective total hip replacements and after fragility femoral neck fractures in nonagenarians

BackgroundHip hemiarthroplasty has traditionally been used to treat displaced femoral neck fractures in older, frailer patients whilst total hip replacements (THR) have been reserved for younger and fitter patients. However, not all elderly patients are frail, and some may be able to tolerate and benefit from an acute THR. Nonagenarians are a particularly heterogenous subpopulation of the elderly, with varying degrees of independence. Since THRs are performed electively as a routine treatment for osteoarthritis in the elderly, its safety is well established in the older patient. The aim of this study was to compare the safety of emergency THR to elective THR in nonagenarians.MethodsA retrospective 10-year cohort study was conducted using data submitted to the National Hip Fracture Database (NHFD) across three hospitals in one large NHS Trust. Data was collected from 126 nonagenarians who underwent THRs between 1st January 2010 – 31st December 2020 and was categorised into emergency THR and elective THR groups. Mortality rates were compared between the two groups. Secondary outcomes were also compared including postoperative complications (dislocations, revision surgeries, and periprosthetic fracture), length of stay in hospital, and discharge destination.ResultsThere was no significant difference in mortality between the two groups, with 1-year mortality rates of 11.4% and 12.1% reported for emergency and elective patients respectively (p = 0.848). There were no significant differences in postoperative complication rate and discharge destination. Patients who had emergency THR spent 5.56 days longer in hospital compared to elective patients (p = 0.015).ConclusionThere is no increased risk of 1-year mortality in emergency THR compared to elective THR, in a nonagenarian population. Therefore, nonagenarians presenting with a hip fracture who would have been considered for a THR if presenting on an elective basis should not be precluded from an emergency THR on safety grounds.Trial registrationNot necessary as this was deemed not to be clinical research, and was considered to be a service evaluation.

The role of depression in the association between mobilisation timing and live discharge after hip fracture surgery: Secondary analysis of the UK National Hip Fracture Database.

The aim was to compare the probability of discharge after hip fracture surgery conditional on being alive and in hospital between patients mobilised within and beyond 36-hours of surgery across groups defined by depression. Data were taken from the National Hip Fracture Database and included patients 60 years of age or older who underwent hip fracture surgery in England and Wales between 2014 and 2016. The conditional probability of postsurgical live discharge was estimated for patients mobilised early and for patients mobilised late across groups with and without depression. The association between mobilisation timing and the conditional probability of live discharge were also estimated separately through adjusted generalized linear models. Data were analysed for 116,274 patients. A diagnosis of depression was present in 8.31% patients. In those with depression, 7,412 (76.7%) patients mobilised early. In those without depression, 84,085 (78.9%) patients mobilised early. By day 30 after surgery, the adjusted odds ratio of discharge among those who mobilised early compared to late was 1.79 (95% CI: 1.56-2.05, p<0.001) and 1.92 (95% CI: 1.84-2.00, p<0.001) for those with and without depression, respectively. A similar proportion of patients with depression mobilised early after hip fracture surgery when compared to those without a diagnosis of depression. The association between mobilisation timing and time to live discharge was observed for patients with and without depression.

ORTHOPOD: Linking ambulatory future trauma injury distribution from fragility proximal femur fracture caseload

IntroductionThe age of those experiencing traumatic injury and requiring surgery increases. The majority of this increase seen in older patients having operations after accidents is in fragility proximal femur fractures (FPFF). This study designed a model to predict the distribution of fractures suitable for ambulatory trauma list provision based on the number of FPFF patients. MethodsThe study utilized two datasets which both had data from 64 hospitals. One derived from the ORTHOPOD study dataset, and the other from National Hip Fracture Database. The model tested the predictability of 12 common fracture types based on FPFF data from the two datasets, using linear regression and K-fold cross-validation. ResultsThe predictive model showed some promise. Evaluation of the model with mean RMSE and Std RMSE demonstrated good predictive performance for some fracture types, although the r-squared values showed that large variation in these fracture types was not always captured by the model. The study highlighted the dominance of FPFFs, and the strong correlation between these and numbers of ankle and distal radius fractures at a given unit. DiscussionIt is possible to model the numbers of ankle and distal radius fractures based off the number of patients admitted with hip fractures. This has great significance given the drive for increased day case utilisation and bed pressures across health services. While the model's current predictability was limited, with methodological improvements and additional data, a more robust predictive model could be developed to aid in the restructuring of trauma networks and improvement of patient care and surgical outcomes.

Fragility Fracture Network-Japan: The challenge of establishment of a national hip fracture database and successful achievement of nationwide health system change for hip fracture care in Japan

BackgroundIn April 2022, a new reimbursement scheme for hip fracture was implemented by the Japanese health ministry. Japan is one of the world's most aged societies, facing a significant, rapidly growing burden of osteoporosis and fragility fractures. The incidence of hip fractures is projected to increase from 240,000 in 2020 to 320,000 by 2040. In 2015, Fragility Fracture Network-Japan (FFN-Japan) was formally established as a nonprofit organization in order to create the optimal fragility fracture care system in Japan. MethodsFFN-Japan launched the Japan National Hip Fracture Database (JNHFD) in 2017, initially with only eight participating hospitals across Japan. The number of patients enrolled from May 2017 to the end of 2020 in the JNHFD from the 16 hospitals registered the patients during this period with amounting to 4271 patients in total. FFN-Japan invited officials from the Ministry of Health, Labor and Welfare (MHLW) to participate in round table meetings to discuss the data collected in the JNHFD and to consider opportunities for nationwide improvement in hip fracture care. ResultsThe proportion of patients who underwent surgery within 36 h of arrival at hospital was 48.1% in 2018, 58.6% in 2019, and 44.9% in 2020 indicating the delay of surgery. Regarding secondary fracture prevention, initiation of osteoporosis treatment during the in-patients was 60.2% in 2018, 54.0% in 2019, and 64.5% in 2020 indicating the inadequate post fracture care. In April 2022, the Central Social Insurance Medical Council of the Japanese MHLW announced a new reimbursement scheme for hip fracture care including two key components: Early surgery (within 48 h from injury) and Secondary fracture prevention immediately after fracture. DiscussionThe new reimbursement scheme of hip fracture care in Japan will catalyze and underpin major improvements on acute multidisciplinary care and post-fracture care with secondary fracture prevention. FFN-Japan played a key role on these policy changes to the health system by means the close collaboration and ongoing communication with the government. ConclusionWithin five years of establishment of the JNHFD, FFN-Japan in collaboration with visionary leaders from the Japanese government have successfully achieved a major reform of the Japanese health system's reimbursement of hip fracture care. This reform has laid the foundation for transformation of management of this debilitating and life-threatening injury that currently afflicts almost a quarter of a million older Japanese citizens each year.

The impact of anticoagulant medications on fragility femur fracture care: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

IntroductionDue to their hypocoagulable state on presentation, anticoagulated patients with femoral fragility fractures typically experience delays to surgery. There are no large, multicentre studies previously carried out within the United Kingdom (UK) evaluating the impact of anticoagulant use in this patient population. This study aimed to evaluate the current epidemiology and compare the perioperative management of anticoagulated and non-anticoagulated femoral fragility fracture patients. MethodsData was prospectively collected through a collaborative, multicentre approach involving hospitals across the United Kingdom. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Main outcomes under investigation included time to surgery, receipt of blood transfusion between admission and 48 h following surgery, length of stay, and 30-day mortality. These were assessed using multivariable linear and logistic regression, and Cox proportional hazards models. Only data from hospitals ≥90 % case ascertainment with reference to figures from the National Hip Fracture Database (NHFD) were analysed. ResultsData on 10,197 patients from 78 hospitals were analysed. 18.5 % of patients were taking anticoagulants. Compared to non-anticoagulated patients, time to surgery was longer by 7.59 h (95 %CI 4.83–10.36; p < 0.001). 42.41 % of anticoagulated patients received surgery within 36 h (OR 0.54, 95 %CI 0.48–0.60, p < 0.001). Differences in time to surgery were similar between countries however there was some variation across units. There were no differences in blood transfusion and length of stay between groups (OR 1.03, 95 %CI 0.88–1.22, p = 0.646 and 0.22 days, 95 %CI -0.45–0.89; p = 0.887 respectively). Mortality within 30 days of admission was higher in anticoagulated patients (HR 1.27, 95 %CI 1.03–1.57, p = 0.026). ConclusionsAnticoagulated femoral fragility fracture patients comprise a substantial number of patients, and experience relatively longer delays to surgery with less than half receiving surgery within 36 h of admission. This may have resulted in their comparatively higher mortality rate. Inclusion of anticoagulation status in the minimum data set for the NHFD to enable routine auditing of performance, and development of a national guideline on the management of this growing and emerging patient group is likely to help standardise practice in this area and improve outcomes.

Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients.

Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes. 21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score. The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group. Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

1971 Five years of the National Audit of Inpatient Falls

Abstract Introduction There are around 250,000 inpatient falls in English hospitals each year. Inpatient falls are associated with poor outcomes. Evidence suggests multifactorial assessment and intervention is the most effective way to prevent inpatient falls. There are National Institute of Health and Care Excellence (NICE) quality standards for safe post fall management. National audit supports improvement in the quality and safety of clinical care. Methods The National Audit of Inpatient Falls (NAIF) began collecting continuous data from all femoral fractures (as identified on the National Hip Fracture Database) in England and Wales from 2019. Prospective documentation review collects data on multifactorial falls risk assessment (MFRA) prior to the femoral fracture as well as immediate post fall management and presents performance indicators related to NICE guidelines/quality standards. Results There are around 2000 inpatient femoral fractures each year. Those with an inpatient fracture have double the 30-day mortality of those who fracture elsewhere, highlighting the vulnerability of this group of patients. There has been improvement in most aspects of MFRA and the proportion of patients checked for injury before moving from the floor has increased from 69 to 77%, use of flat lifting equipment from 22 to 29% and medical assessment within 30mins of the fall from 52 to 60%. Conclusion There have been steady improvements in guideline compliant inpatient fall-prevention and post-fall management, but there is more to do. The programme also produces improvement resources and activities and will be expanding the range injuries covered in the next 2 years.

1850 Dogs and Bones

Abstract Introduction The health benefits of owning dogs include improved physical activity, mental well-being, companionship, and so forth. However, musculoskeletal injuries caused by dog-related activities might negate the aforementioned benefits. The aim of this study was to estimate the number of femoral fractures directly linked to dog-related activities in people above the age of 60. Methods In this observational study, we included all patients above the age of 60 with femoral fractures caused by dog-related activities, over a one-year period (June 2022 to May 2023). We chose to include people above the age of 60 because they are more likely to have a fragility fracture and are entered in the National Hip Fracture Database. Results 387 patients (above the age of 60) were admitted with femoral fractures during the study period. Of these, 16 were directly related to dog-related activities. The common mechanisms of injuries include being tripped, pulled down and jumped over by a dog, and tangled and tripped by the dog leash. Conclusion 4% of femoral fractures (1 in 25) in people above the age of 60 were caused by dog-related activities. This is probably an underestimate, because some owners may not have volunteered this information out of love for their dogs and inadequate history regarding the circumstances that led to the fall. Despite the injuries, all patients still loved their dogs and wanted to go home as soon as possible to be with them. There were more fractures in spring and summer (11) compared to autumn and winter (5) which reflects increased activity with better weather. Having a dog is a risk factor for falls and fractures. We recommend that dog owners carefully consider their choice of dogs and if there are issues with handling them, both dogs and their owners should receive appropriate training.

ORTHOPOD: PREDICTING INJURY PROPORTIONALITY FROM NECK OF FEMUR FRACTURES

AbstractObjectivesThe need to accurately forecast the injury burden has never been higher. With an aging, ever expanding trauma population and less than half of the beds available compared to 1990, the National Health Service (NHS) is stretched to breaking point1,2. Resultantly, we aimed to determine whether it is possible to predict the proportionality of injuries treated operatively within orthopaedic departments based on their number of Neck of Femur fracture (NOF) patients reported both in our study and the National Hip Fracture Database (NHFD).MethodsWe utilised the ORthopaedic trauma hospital outcomes - Patient operative delays (ORTHOPOD) dataset of 22,585 trauma patients across the four countries of the United Kingdom (UK) admitted to 83 hospitals between 22/08/22 – 16/10/22. This dataset had two arms: arm one was assessing the caseload and theatre capacity, arm two assessed the patient, injury and management demographics.ResultsOur results complied with the data reported to the NHFD in over 80% of cases for both the 2022 and five-year average reported numbers. More operations were performed for elderly hip fractures alone than for the combined totals of the next four most common fractures: ankle, distal radius, tibial shaft and forearm (6387 vs 5922). Conversely, 10 out of the 13 fracture types were not encountered by at least one hospital and 93% of hospitals encountered less than 2 fractures of a certain type.60% of trauma is treated within Trauma Units (TUs) however, per unit, Major Trauma Centres (MTCs) treat approximately 43% more patients. Similarly, 11 out of the 14 fracture types examined presented more frequently to a MTC however 3 of the most common fractures had a preponderance for TUs (elderly hip, distal radius and forearm fractures). After excluding NOF, lower limb fractures accounted for approximately 57% of fractures in all countries and ankle and distal radius fracture combined comprised more than 50% in 74% of regions. There were few outliers across the study regarding number of fractures treated by a hospital with tibial shaft fractures demonstrating the highest number of outliers with 4.ConclusionsThe number of hip fractures seen on average by an individual unit remains relatively consistent as does the regional variation of any given fracture; resultantly, it is possible to predict injury proportionality based off a unit's hip fracture numbers. This powerful tool could transform both resource allocation and recruitment.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

An orthogeriatric service can reduce prolonged hospital length of stay in hospital for older adults admitted with hip fractures: a monocentric study

BackgroundThe Blue Book (2005), recommended guidelines for patients care with fragility fractures. Together with introduction of a National Hip Fracture Database Audit and Best Practice Tariff model to financially incentivise hospitals by payment of a supplement for patients whose care satisfied six clinical standards), have improved hip fracture after-care. However, there is a lack of data-driven evidence to support its effectiveness. We aimed to verify the impact of an orthogeriatric service on hospital length of stay (LOS)—duration from admission to discharge.MethodsWe conducted a repeated cross-sectional study over a 10 year period of older individuals aged ≥ 60 years admitted with hip fractures to a hospital.ResultsAltogether 2798 patients, 741 men and 2057 women (respective mean ages; 80.5 ± 10.6 and 83.2 ± 8.9 years) were admitted from their own homes with a hip fracture and survived to discharge. Compared to 2009–2014, LOS during 2015–2019, when the orthogeriatric service was fully implemented, was shorter for all discharge destinations: 10.4 vs 17.5 days (P < 0.001). Each discharge destination showed reductions: back to own homes, 9.7 vs 17.7 days (P < 0.001); to rehabilitation units: 10.8 vs 13.1 days (P < 0.001); to residential care: 15.4 vs 26.2 days (P = 0.001); or nursing care, 24.4 vs 53.1 days (P < 0.001). During 2009–2014, the risk of staying > 3 weeks in hospital was greater by six-fold and pressure ulcers by three-fold. The number of bed days for every thousand patients per year was also shortened during 2015–2019 by: 1665 days for discharge back to own homes; 469 days with transfer to rehabilitation units; 1258 days for discharge to residential care, and 5465 days to nursing care. Estimated annual savings (2017 costs) per thousand patients after complete establishment of the service was about £2.7 m.ConclusionsImplementation of an orthogeriatric service generated significant reductions in hospital LOS for all patients, with associated cost-savings, especially for those discharged to nursing care.

366 Vitamin D3 Assessment and Supplementation in Elderly Hip Fracture Patients: A Closed Loop Quality Improvement Project

Abstract Aim to improve the assessment and supplementation of vitamin D3 in elderly hip fracture patients in a trauma unit. Method This is a single-centre quality improvement project utilising the PDSA cycle based in a trauma unit covering the black country within the West Midlands. Data was collected retrospectively using the National Hip Fracture Database and hospital electronic systems such as clinical web portal, ICE, GP records, edischarge and ePMA. Inclusion criteria consisted of patient age greater than 60 with a radiologically confirmed neck of femur fracture, treated operatively with an orthogeriatrics review within 72 hours of admission, and COVID-19 negative PCR. Pre-intervention data included 15 patients from July 2020. We assessed 3 parameters including pre-admission vitamin D3 supplementation, measurement of vitamin D3 during admission and vitamin D3 supplementation on discharge. Interventions placed in February 2021 comprised of a postoperative hip blood profile pathway on ICE and guidelines on how to order bloods were circulated with information posters. In addition, teaching sessions for doctors and nurses with twice weekly orthogeriatric reviews emphasising bone protection. Post-intervention data included 15 patients from April 2021. Results Improvement in vitamin D3 level assessment during admission; 20% to 93.3% however, decline in vitamin D3 supplement prescribed on discharge; 73.3% to 26.7%. Conclusions Interventions showed an improvement in quality of vitamin D3 assessment however, the decline in supplementation on discharge may be due to further planned intravenous bone protection bisphosphonate therapy and miscommunication due to ward doctors rotating every 4-6 months on how to appropriately assess and supplement vitamin D3 levels.

899 Administration of Fascia-Iliaca Blocks for Hip Fracture Patients on Admission to the A&amp;E Department at Southport DGH

Abstract Aim Fascia-iliaca block (FIB) is regional anaesthetic used in A&amp;E for hip fractures; they’re performed under landmark guidance in Southport A&amp;E. NICE recommend FIBs for hip fractures if PO/IV paracetamol/opiates provide insufficient relief; it’s shown to provide superior analgesia and reduce opiate consumption. RCEM state FIBs should be administered promptly in A&amp;E by trained personnel and are a listed ACCS competency. The audit aim was to review the number/percentage of hip fracture patients receiving FIBs, with documentation, in Southport A&amp;E. Hip fracture patients should have documented FIBs, the standard for the audit was ≥90% patients. Method This audit was a retrospective analysis of the 6-week period 08/08/2022-20/09/2022 for hip fracture patients at Southport DGH. Data was collected from the National Hip Fracture Database. Patients weren’t delayed to surgery on FIB administration. Online inpatient/A&amp;E notes and drug charts were analysed for FIB documentation. Results The sample included 46 patients, 8 male and 38 female. 13 had documented FIBs on admission, 33 had no documented FIB, meaning 28.2% of patients received FIBs in A&amp;E over 6-weeks. Conclusions This audit shows too few hip fracture patients are receiving FIBs in Southport A&amp;E as analgesia, with 28.2% documented compared to the desired ≥90% standard. Patients are either not receiving FIBs or not having them documented. FIB use can be improved by clinical audit, and interventions are being implemented to improve use in Southport A&amp;E, including posters, hip fracture proforma additions, and department education.

1081 The Challenge of Fixing Multi-Fragmentary Neck of Femur Fractures: A Retrospective Case Control Study for Unstable A2 Type Neck of Femur Fractures Fixed with Dynamic Hip Screws, and Short Intramedullary Nails

Abstract Aim Not all Neck of Femur (NOF) fractures are equivalent. AO-A2 subtype are multi-fragmentary and include a lesser trochanter fracture; they can be inherently unstable. Some believe Intramedullary Nails (IMN) offer greater stability however there is concern regarding increased operative time and blood loss. This project compared operative time and perioperative blood loss between Dynamic Hip Screw (DHS) and IMN used to treat matched groups of A2 NOF fractures. Method A patient list was compiled from the national hip fracture database from 01/01/2020 to 31/05/2022. Fractures were classified according to AO standards; radiographs pre- and post-surgery, blood results, and operative records were reviewed. Results A total of 41 IMNs were performed for A2 NOF fractures, a comparison group of 41 patients treated with DHS was created. Patients were matched for ASA grade. The IMN group had an average ASA of 3.0 (DHS 3.1), perioperative haemoglobin drops of 30.8 (DHS 29.8), operation time of 64 minutes (DHS 57), and Tip Apex Distance (TAD) of 19.6mm (DHS 24.8). The difference in perioperative haemoglobin drop and operating time were not statistically significant. The TAD was significantly lower in the IMN group. Conclusions There was no difference in surgical time or perioperative blood loss. An improved TAD in the IMN group, despite less surgical experience with this implant, may correlate with lower long-term rates of failure. Our project suggests IMN is a safe implant, at least in the short term for A2 fractures, but further research of long-term benefits including mobility and pain is required.