Subscribe to RSS
DOI: 10.1055/a-2276-6440
Are Process Changes Measurable? An Analysis of 4136 Proximal Femur Fractures over 16 Year
Article in several languages: English | deutsch
Zusammenfassung
Einleitung
Prozessänderungen im perioperativen Setting werden selten analysiert, weil ihre Ergebnisse nicht unmittelbar fassbar sind und es einer hohen Fallzahl bedarf. Primäres Ziel war es, Prozessänderungen retrospektiv anhand proximaler Femurfrakturen (PF) zu evaluieren und deren Effekt mit verschiedenen Zielkriterien zu überprüfen. Sekundäres Ziel war die Definition möglicher Qualitätskriterien für die Versorgung von PF.
Patienten/Material
Retrospektive Analyse der Datenbank eines Level-1-Traumazentrums zu PF. Eingeschlossen wurden alle osteosynthetisch und endoprothetisch versorgten PF im Behandlungszeitraum vom 01.01.2006 bis 31.12.2021. Der Zeitraum von 16 Jahren wurde für die Statistik trichotom aufgeteilt und die ersten 6 Jahre als Ausgangsbasis verwendet. Insgesamt 10 Prozessänderungen wurden in den folgenden 10 Jahren vorgenommen. Die Auswirkungen dieser Änderungen wurden anhand 1. der operativen Revisionsrate, 2. der Infektionsrate, 3. der perioperativen Transfusionsrate sowie 4. der 1-Jahres-Letalität überprüft.
Ergebnisse
Insgesamt 4163 PF wurden analysiert. Hinsichtlich der Zielkriterien zeigten die Änderungen der ersten 5 Jahre (2012–2016; intramedulläres Verfahren für Osteosynthesen sowie Einwegabdeckung und Einwegkittel) den stärksten Effekt mit einer erstmaligen Senkung der operativen Revisionsrate unter 10% auf Dauer. Weitere Prozessoptimierungen der letzten 5 Jahre (2017–2021) erbrachten ebenfalls messbare Verbesserungen (Senkung der Infektions- und Transfusionsrate). Die 1-Jahres-Letalität blieb unverändert, auch während der COVID-19-Pandemie.
Schlussfolgerung
Prozessänderungen bei PF führen nicht unmittelbar zu objektiv messbaren Verbesserungen. Rückblickend erscheint der Paradigmenwechsel von extra- auf intramedulläre Osteosynthese den höchsten Effekt erzielt zu haben, wenngleich über die letzten 10 Jahre eine schrittweise Besserung aller Zielkriterien eintrat – mit Ausnahme der Letalität. Als objektive Qualitätskontrolle sollte eine 1-Jahres-Revisionsrate unter 10% angestrebt sein.
#
Introduction
Treatment of proximal femoral fractures (PF), which predominantly occur in the geriatric population, is one of the most common and regularly performed operations in a trauma surgery clinic [1] [2]. In this operation, the setting and surgical procedure should be performed in a standardised manner throughout, and the perioperative results are now also made available across different centres or analysed for health insurance purposes [3]. Examples include AltersTraumaRegister DGU, the Registry for Geriatric Trauma of the German Society for Trauma Surgery, or the health sector external quality assurance (EQS) databases [4] [5] [6]. However, results from these analyses encompassing a postoperative follow-up of at least one year are not yet envisaged [3] [5] [6] [7].
PFs that are [8] type 31-A1–A3 under the classification system of the Working Group for Osteosynthesis are generally operated on a joint-preserving basis. With type AO 31-B1–B3 factures the preferred approach is joint replacement by endoprosthesis, especially in geriatric patients, although there may be individual variations due to age, level of activity, morbidity, and bone quality [9] [10].
To date, a search of the literature and guidelines does not reveal any numerical threshold that could be used as a quality criterion for treatment of PF. There is also an absence of directives on how clinics should monitor their own processes, which are often standardised. This might involve, for example, determining a critical upper limit for the number of surgical revisions carried out within one year of the initial operation. The rate of infection or the number of RBC concentrates used during the operation, as well as the mortality rate, could also provide objective indicators of quality. However, the latter parameter of mortality is often presented without reference to the femoral fracture [3] [11]. In addition, the current quality control system in Germany covers a much shorter period of time and only checks whether certain clinics stand out against the national average [4]. In general, absolute limits have not yet been determined.
Process changes in clinics evolve over a period of many years, and are evaluated first and foremost from an economic perspective. With PF, for example, this might involve the introduction of new implants that are more cost-effective. On the other hand, there have also been changes that cannot initially be measured in economic terms, such as minimally invasive access routes [12].
To the best of our knowledge, there has so far been very little scientific analysis of such changes in surgical processes in relation to PF [13]. Reasons for this may include the large number of potential variables, the high number of cases required, and the length of study period necessary in order to adequately capture relevant target criteria.
We therefore decided to conduct this monocentric, retrospective study, based on a long study period with high case numbers, so as to identify how process changes manifest in the outcomes, and to evaluate a possible target criterion. This criterion could be used in future for quality control (including in our own clinic) of the surgical treatment of PF.
#
Materials and Methods
The study is based on a continually maintained electronic database (Excel file) that includes all PFs treated surgically at the clinic since 1 January 2006, with a postoperative follow-up period of at least one year for every patient (still living). The database has multiple perioperative and postoperative variables, including surgical revisions and survival time. The data are entered continuously by the original author, and updated regularly based on the electronically filed outpatient and inpatient medical records. Some missing data are supplemented or completed prospectively, but mostly this is done retrospectively through telephone calls with patients or, in the case of dementia, with their relatives.
All patients with PF (femoral neck, pertrochanteric, and subtrochanteric fractures) who were treated surgically between 1 January 2006 and 31 December 2021 were included in this study, regardless of age, aetiology, or concomitant diseases and injuries. Exclusion criteria were traumatic femoral head fractures, isolated trochanter fractures, or periprosthetic fractures.
For this study, the baseline variables were initially the annual number of cases, age and gender, body mass index (kg/m 2), and surgeries performed (dynamic hip screw [DHS], proximal femur nail [PFN], total endoprosthesis, hemiprosthesis) ([Table 1]). The same implants were used throughout the study; there was no change in manufacturer at any time. All operations were either performed in person or assisted by senior trauma surgeons, or at least by physicians who met the standard for this specialisation.
Throughout the study period, without exception all surgical procedures were performed under general anaesthesia. Perioperative antibiotic treatment was routinely administered intravenously using a first-generation cephalosporin (exception: clindamycin was used as an alternative in patients known to have an allergy). Osteosynthesis was performed as standard on an extension table.
Process Changes
The process changes and their implementation time ([Table 2]) are clearly documented using the corresponding process instructions. In addition, the changes were able to be accurately traced through information reported by long-term staff members.
The perioperative baseline between 2006 and 2011 remained the same: 1. Sterile multi-use drapes, sterile multi-use kit, no surgical film; 2. Dynamic hip screw, possibly with trochanter stabilising plate, as the treatment of choice for pertrochanter fractures; 3. Total endoprosthesis as the treatment of choice including for geriatric patients, displaced femoral neck fractures accessed via the Watson-Jones access with patient in supine position, using subfascial and subcutaneous drainage as standard. 4. Hemiprosthesis only for bedridden, immobile patients.
In 2012, for the first time, single-use drapes (single-use vertical wipes for extension tables) and a bactericidal surgical film were used consistently. In terms of osteosynthesis, there was a paradigm shift from DHS to PFN as the treatment of choice for unstable pertrochanteric fractures, particularly fractures with no medial support (type AO 31-A1.3–A3.3) [14] [15]. To date, DHS is still used for type AO 31-A1 fractures.
In 2015/2016, the minimally invasive Röttinger [12] access for endoprosthetic surgery was gradually established.
In 2016, three new operating rooms were built, directly adjoining the existing operating wing.
As of 2017, process instructions on coagulation management were implemented as part of training for medical and nursing staff. This includes detailed recommendations for the perioperative management of patients already taking anticoagulants, which were validated through an appropriate literature search [16] [17] [18] as well as interdisciplinary input. For example, risk stratification for thromboembolism and bleeding is used to determine whether the drug in question (new oral anticoagulants [NOAC], Marcumar) should be paused or continued, or whether bridging with heparin should be performed.
In this context, the use of drains was avoided [19]. Likewise, weekly meetings to discuss complications were held from this point onwards.
In 2018, for the first time, surgery was consistently performed within 24 hours of admission (> 85%), ultimately based on the requirements of the Institute for Quality Assurance and Transparency in Healthcare (IQTIG), as well as the 2019 decision of the Federal Joint Committee (G-BA) [20]. In addition, there was a gradual paradigm shift from total endoprosthesis to cemented hemiprosthesis in patients aged > 80 with a displaced femoral neck fracture [21] [22].
In 2019, a dedicated unit was set up for interdisciplinary complex orthogeriatric care (20 beds in the trauma surgery clinic), and the concept of local infiltration anaesthesia (LIA) was established in endoprosthesic surgery [23], in combination with tranexamic acid administered intravenously (initially 1 g IV, then 0.5 g at 8 hours and 24 hours after surgery), or by intra-ariticular route as a bolus of 2 g after fascia closure if intravenous administration was contraindicated (e. g., history of cerebral or cardiac infarction, atrial fibrillation) [24].
The primary endpoints for the study were surgical revision rate, infection rate (according to criteria from the working group of the Musculoskeletal Infection Society) [25], rate of perioperative transfusion with RBC concentrates, and 1-year lethality over the period following each of the process changes introduced. A secondary objective was to evaluate and implement a possible variable as a future objective quality control.
The study was conducted in accordance with the guidelines of the Declaration of the World Medical Association of Helsinki and was approved by the local ethics committee. Verbal consent was obtained from all patients or their relatives, who were contacted by telephone.
#
Statistics
For the statistical evaluation, the years 2006–2011 were used as the baseline, with no process changes occurring. The following 10 years were divided into two parts for statistical evaluation (2012–2016 and 2017–2021).
The analyses were performed using the statistical software SPSS for Windows, version 24.0 (SPSS Inc., Chicago, USA). The data were presented as nominal numbers, mean values, or percentages (%). The groups were statistically tested using the chi-square test.
#
#
Results
A total of 4,163 consecutive proximal femoral fractures were included in the study, with a linear increase in the number of cases over a period of approximately 16 years. The absolute increase was 87.4% (2006: n = 175; 2021: n = 328). As expected, 2020 showed a slightly lower number of cases due to the COVID-19 pandemic and the lockdown from 22 March 2020 to 4 May 2020 ([Table 1]).
The baseline variables: mean patient age, gender distribution, and body mass index (BMI) remained consistent without significant variation. Accordingly, there was no increase in mean patient age over 16 years ([Table 1]).
Although the process changes did not immediately improve the target criteria ([Table 3]), the data show that they resulted in a gradual improvement in all target criteria – except for 1-year lethality. The latter criterion was always well below 30% per year.
In summary, compared to baseline, the two 5-year evaluations ([Table 4]) show a significant reduction of 55% (from 15.7% down to 7.3%) in the surgical revision rate, a 68% reduction (from 4.4% to 1.4%) in the infection rate, and a 45% reduction (from 63.3% to 34.7%) in the RBC transfusion rate (number of patients without any transfusion).
A subgroup analysis of patients with endoprosthetic treatment (n = 1,760) showed similar significant effects ([Table 5]).
Based on our analysis of the data and of our target criteria over time, we can ultimately conclude that a 1-year surgical revision rate of less than 10% could be considered an objective criterion or threshold for quality assurance in the treatment of PF in the future.
#
Discussion
Strengths of the Study
The scientific analysis of changes in surgical processes in relation to PF is a novelty, at least in Germany. For one thing, this requires a very high number of cases in order to capture small differences in the target criteria. In addition, the target criteria need to be defined in such a way that the results of the process changes can be objectively verified. In our view, these two basic requirements are fully met in this study.
Of course, it is not possible to analyse and evaluate all of the potential factors or variables affecting the defined target criteria in a single study. As many as 13 perioperative measures aimed at preventing or reducing postoperative infections have been described by the World Health Organization (WHO) [26]. In this context, even the number of people present in the operating room or the number of times the door is opened during the operation have a strong correlation with microbial air contamination [27]. The human factor, in this case surgeons with differing skill levels, as well stress factors that occur on a daily basis (OP timing, fatigue, experience, workload, team composition, etc.) are left out in any case, because it is difficult to measure these factors objectively in a reproducible manner in a real-life context.
Nevertheless, the surgical revision rate and the infection rate in particular are the criteria that can be considered most apt to capture the outcome of PF treatment, and these parameters are also regularly evaluated in multicentric surveys and registry data [21] [27] [28].
A recent and unique study by Lian et al. demonstrates a similar approach to the one used in our study, with very similar results [13]. The authors investigated six structural changes in the surgical care of hip fractures using hemiprosthetics. The changes included: 1. surgery within 48 hours, 2. proper antibiotic prophylaxis, 3. cemented shaft, 4. at least 2 surgeons in addition to the senior surgeon, 5. multidisciplinary orthogeriatric team, and 6. osteoporosis prophylaxis. The authors found that these measures resulted in a 60% reduction in the rate of major complications, as well as a reduction in the surgical revision rate from 12.6% to 4.9%, with mortality remaining constant. Compared to our study, Lian et al. [13] based their study on a small number of cases (n = 475) and a shorter study period (2012–2015). A strength of our study lay in the consistent baseline parameters for the years 2006–2011, during which there were no changes in personnel, materials, or medical settings.
With the exception of new operating rooms added to the operating wing and the dedicated unit for complex orthogeriatric treatment which was later set up, the process changes that were implemented over the following 10 years were initially based on a paradigm shift. For example, in the treatment of AO 31-A1.3–A3.3-type PFs, DHS and trochanter stabilising plates were gradually replaced by intramedullary bone marrow nails. Scandinavian registry data confirm this trend, which is accompanied by lower revision rates and better outcomes [29] [30]. The numerical changes in our own clinic are shown in [Table 1]. In addition, the multi-use drapes and multi-use kits have been replaced with single-use items.
The other measures, particularly during the last quarter of the study from 2017–2021, are based on study results [16] [17] [18] [21] [22] [23] [24] [31] [32] which were implemented gradually. From our point of view, therefore, the years 2019–2021, in which all of the measures were routinely applied, can be considered to reflect a modern treatment regime. This includes surgical care within 24 hours of admission (including on weekends), generally also when the patient is taking Marcumar or new oral anticoagulants (NOACs), minimally invasive surgical techniques without drainage insertion, and the use of the LIA concept and tranexamic acid.
Interestingly, none of the 10 process changes showed a clear or significant improvement in the target criteria in the immediate following year; instead, the measures only yielded numerical improvement over time in small steps. Ultimately, however, within 10 years there was a significant reduction in surgical revision and infection rates, at over 50%, as well as a 45% reduction in transfusion rates.
On the other hand, no reduction in 1-year lethality was observed over the 16-year period, despite the introduction of a dedicated unit for complex orthogeriatric treatment. Our data are in contrast to a recent observational study of 58,000 patients in which the adjusted 30-day lethality was 22% lower in hospitals with orthogeriatric co-management vs. without [7]. However, 1-year results are missing from this study. Consistent with our analysis, Mundi et al. saw no significant change in 1-year lethality (as well as revision rates) in a review of 70 randomised studies over a 31-year period (1981–2012) [33]. Danish registry data also confirm this for the period 2000–2014 [28]. Current German insurance data for the years 2007/2008 vs. 2017/2018 also show a stable perioperative mortality rate of 6% [3].
For all three target criteria, there is so far no obvious value or range that can be taken as indicating a good standard of surgical treatment. In contrast, there is an established threshold for the parameter time from admission to surgery, which is set at 85% of patients being operated within 24 hours [4]. However, this value is not in itself a quality criterion for the postoperative outcome.
In our view, supported by the results, a 1-year revision rate of less than 10% could be used in future as a target in this context. With regard to the rate of infection, it is much more difficult to set a threshold because of the lower incidence. Even within our cohort, the annual evaluations were subject to large fluctuations. In terms of the transfusion rate, at least 50% of patients in the perioperative setting should no longer require transfusions of RBC concentrates.
#
Limitations of the Study
The study has several limitations. Firstly, the data was collected retrospectively at one study site only, which detracts from the robustness of the evidence. This means that the results are not universally valid. Secondly: variables separate from the process changes may also have influenced the target criteria, such as the personal experience and surgical skill of the individual surgeons. However, it is the case that the senior medical team has not changed significantly in its composition over many years, so the learning curve here may remain flat over a long period. Third: organisational aspects such as room allocation or the timing of the operation (day versus night or weekends) were also not taken into account. Fourth: general complications such as pneumonia, pulmonary embolism, or infarction were not identified due to their very low incidence. Fifth: with an endpoint of 1 year after surgery, the study did not capture any late revisions. Sixth: an in-depth description of all measures for complex orthogeriatric treatment or coagulation management guidelines would have been beyond the scope of this publication. Finally, no individual process change can be attributed to an individual target criterion; this is why, in our view, the overall view is crucial.
#
#
Take-Home Message
Over 16 years there has been an almost 90% increase in the incidence of proximal femoral fractures, with constant 1-year lethality. Process changes did not immediately result in measurably better results; however, the patient cohort in this study did show a gradual reduction in revision and infection rates, as well as in transfusion frequency. As a quality criterion, the authors recommend a surgical revision rate of less than 10% during the first postoperative year.
#
#
Conflict of Interest
The authors declare that they have no conflict of interest.
-
References
- 1 Baidwan NK, Naranje SM. Epidemiology and recent trends of geriatric fractures presenting to the emergency department for United States population from year 2004–2014. Public Health 2017; 142: 64-69
- 2 Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register. BMC Musculoskelet Disord 2018; 19: 369
- 3 Neumann CJ, Schulze-Raestrup U, Müller-Mai CM. et al. Entwicklung der stationären Versorgungsqualität operativ behandelter Patienten mit einer proximalen Femurfraktur in Nordrhein-Westfalen. Eine Analyse über 61.249 Behandlungsverläufe auf Grundlage der Daten der externen stationären Qualitätssicherung. Unfallchirurgie 2022; 125: 634-646
- 4 Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG). Accessed November 01, 2023 at: https://www.iqtig.org
- 5 Schoeneberg C, Aigner R, Pass B. et al. Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: a retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®. Injury 2021; 52: 554-561
- 6 Schoeneberg C, Knobe M, Babst R. et al. 120-Tage-Follow-up nach hüftgelenknahen Frakturen – erste Daten aus dem AltersTraumaRegister DGU®. Unfallchirurg 2020; 123: 375-385
- 7 Rapp K, Becker C, Todd C. et al. The association between orthogeriatric co-management and mortality following hip fracture. Dtsch Arztebl Int 2020; 117: 53-59
- 8 Marsh JL, Slongo TF, Agel J. et al. Fracture and dislocation classification compendium – 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007; 21(10 Suppl): S1-S133
- 9 Fischer H, Maleitzke T, Eder C. et al. Management of proximal femur fractures in the elderly: current concepts and treatment options. Eur J Med Res 2021; 26: 86
- 10 Raaymakers EL. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Traumatol Cech 2006; 73: 45-59
- 11 Müller F, Galler M, Kottmann T. et al. Analyse von 2000 operativ versorgten proximalen Femurfrakturen. Multiple Variablen beeinflussen die Mortalität. Unfallchirurg 2018; 121: 550-559
- 12 Röttinger H. Minimalinvasiver Zugang zum Hüftgelenk (OCM) zur Implantation von Hüftendoprothesen. Oper Orthop Traumatol 2010; 22: 421-430
- 13 Lian T, Brandrud A, Mariero L. et al. 60% reduction of reoperations and complications for elderly patients with hip fractures through the implementation of a six-item improvement programme. BMJ Open Qual 2022; 11: e001848
- 14 Liu Y, Tao R, Liu F. et al. Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA). Injury 2010; 41: 810-817
- 15 Shen L, Zhang Y, Shen Y. et al. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies. Orthop Traumatol Surg Res 2013; 99: 377-383
- 16 Rechenmacher SJ, Fang JC. Bridging anticoagulation: primum non nocere. J Am Coll Cardiol 2015; 66: 1392-1403
- 17 Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood 2012; 120: 2954-2962
- 18 Verma A, Ha ACT, Rutka JT. et al. What surgeons should know about non-vitamin k oral anticoagulants: a review. JAMA Surg 2018; 153: 577-585
- 19 Tjeenk RM, Peeters MP, van den Ende E. et al. Wound drainage versus non-drainage for proximal femoral fractures. A prospective randomised study. Injury 2005; 36: 100-104
- 20 Gemeinsamer Bundesausschuss. Richtlinie zur Versorgung der hüftgelenknahen Femurfraktur. Beschluss vom 22.11.2019. Accessed August 01, 2023 at: https://www.g-ba.de/beschluesse/4069/
- 21 Lewis DP, Wæver D, Thorninger R. et al. Hemiarthroplasty vs total hip arthroplasty for the management of displaced neck of femur fractures: a systematic review and meta-analysis. J Arthroplasty 2019; 34: 1837-1843
- 22 Moerman S, Mathijssen NM, Tuinebreijer WE. et al. Hemiarthroplasty and total hip arthroplasty in 30,830 patients with hip fractures: data from the Dutch Arthroplasty Register on revision and risk factors for revision. Acta Orthop 2018; 89: 509-514
- 23 Andersen LØ, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth 2014; 113: 360-374
- 24 Masouros P, Antoniou G, Nikolaou VS. Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: a meta-analysis of randomized controlled trials. Injury 2022; 53: 294-300
- 25 Parvizi J, Zmistowski B, Berbari EF. et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011; 469: 2992-2994
- 26 Allegranzi B, Zayed B, Bischoff P. et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16: 288-303
- 27 Agodi A, Auxilia F, Barchitta M. et al. Operating theatre ventilation systems and microbial air contamination in total joint replacement surgery: results of the GISIO-ISChIA study. J Hosp Infect 2015; 90: 213-219
- 28 Gundel O, Thygesen LC, Gögenur I. et al. Postoperative mortality after a hip fractures over a 15- year period in Denmark: a national register study. Acta Orthop 2020; 91: 58-62
- 29 Wahlsten LR, Palm H, Gislason GH. et al. Sex differences in incidence rate, and temporal changes in surgical management and adverse events after hip fracture surgery in Denmark 1997–2017: a register-based study of 153,058 hip fracture patients. Acta Orthop 2021; 92: 424-430
- 30 Gjertsen JE, Dybvik E, Furnes O. et al. Improved outcome after hip fracture surgery in Norway. Acta Orthop 2017; 88: 505-511
- 31 Cheung ZB, Xiao R, Forsh DA. Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review. Arch Orthop Trauma Surg 2022; 142: 633-640
- 32 Krebs NM, VanWagner MJ, Marchewka T. et al. Tranexamic acid in the treatment of hip fractures: a clinical review. Spartan Med Res J 2019; 3: 7026
- 33 Mundi S, Pindiprolu B, Simunovic N. et al. Similar mortality rates in hip fracture patients over the past 31 years. Acta Orthop 2014; 85: 54-59
Correspondence
Publication History
Received: 12 September 2023
Accepted after revision: 24 February 2024
Article published online:
15 April 2024
© 2024. Thieme. All rights reserved.
Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
-
References
- 1 Baidwan NK, Naranje SM. Epidemiology and recent trends of geriatric fractures presenting to the emergency department for United States population from year 2004–2014. Public Health 2017; 142: 64-69
- 2 Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register. BMC Musculoskelet Disord 2018; 19: 369
- 3 Neumann CJ, Schulze-Raestrup U, Müller-Mai CM. et al. Entwicklung der stationären Versorgungsqualität operativ behandelter Patienten mit einer proximalen Femurfraktur in Nordrhein-Westfalen. Eine Analyse über 61.249 Behandlungsverläufe auf Grundlage der Daten der externen stationären Qualitätssicherung. Unfallchirurgie 2022; 125: 634-646
- 4 Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG). Accessed November 01, 2023 at: https://www.iqtig.org
- 5 Schoeneberg C, Aigner R, Pass B. et al. Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: a retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®. Injury 2021; 52: 554-561
- 6 Schoeneberg C, Knobe M, Babst R. et al. 120-Tage-Follow-up nach hüftgelenknahen Frakturen – erste Daten aus dem AltersTraumaRegister DGU®. Unfallchirurg 2020; 123: 375-385
- 7 Rapp K, Becker C, Todd C. et al. The association between orthogeriatric co-management and mortality following hip fracture. Dtsch Arztebl Int 2020; 117: 53-59
- 8 Marsh JL, Slongo TF, Agel J. et al. Fracture and dislocation classification compendium – 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007; 21(10 Suppl): S1-S133
- 9 Fischer H, Maleitzke T, Eder C. et al. Management of proximal femur fractures in the elderly: current concepts and treatment options. Eur J Med Res 2021; 26: 86
- 10 Raaymakers EL. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Traumatol Cech 2006; 73: 45-59
- 11 Müller F, Galler M, Kottmann T. et al. Analyse von 2000 operativ versorgten proximalen Femurfrakturen. Multiple Variablen beeinflussen die Mortalität. Unfallchirurg 2018; 121: 550-559
- 12 Röttinger H. Minimalinvasiver Zugang zum Hüftgelenk (OCM) zur Implantation von Hüftendoprothesen. Oper Orthop Traumatol 2010; 22: 421-430
- 13 Lian T, Brandrud A, Mariero L. et al. 60% reduction of reoperations and complications for elderly patients with hip fractures through the implementation of a six-item improvement programme. BMJ Open Qual 2022; 11: e001848
- 14 Liu Y, Tao R, Liu F. et al. Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA). Injury 2010; 41: 810-817
- 15 Shen L, Zhang Y, Shen Y. et al. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies. Orthop Traumatol Surg Res 2013; 99: 377-383
- 16 Rechenmacher SJ, Fang JC. Bridging anticoagulation: primum non nocere. J Am Coll Cardiol 2015; 66: 1392-1403
- 17 Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood 2012; 120: 2954-2962
- 18 Verma A, Ha ACT, Rutka JT. et al. What surgeons should know about non-vitamin k oral anticoagulants: a review. JAMA Surg 2018; 153: 577-585
- 19 Tjeenk RM, Peeters MP, van den Ende E. et al. Wound drainage versus non-drainage for proximal femoral fractures. A prospective randomised study. Injury 2005; 36: 100-104
- 20 Gemeinsamer Bundesausschuss. Richtlinie zur Versorgung der hüftgelenknahen Femurfraktur. Beschluss vom 22.11.2019. Accessed August 01, 2023 at: https://www.g-ba.de/beschluesse/4069/
- 21 Lewis DP, Wæver D, Thorninger R. et al. Hemiarthroplasty vs total hip arthroplasty for the management of displaced neck of femur fractures: a systematic review and meta-analysis. J Arthroplasty 2019; 34: 1837-1843
- 22 Moerman S, Mathijssen NM, Tuinebreijer WE. et al. Hemiarthroplasty and total hip arthroplasty in 30,830 patients with hip fractures: data from the Dutch Arthroplasty Register on revision and risk factors for revision. Acta Orthop 2018; 89: 509-514
- 23 Andersen LØ, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth 2014; 113: 360-374
- 24 Masouros P, Antoniou G, Nikolaou VS. Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: a meta-analysis of randomized controlled trials. Injury 2022; 53: 294-300
- 25 Parvizi J, Zmistowski B, Berbari EF. et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011; 469: 2992-2994
- 26 Allegranzi B, Zayed B, Bischoff P. et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16: 288-303
- 27 Agodi A, Auxilia F, Barchitta M. et al. Operating theatre ventilation systems and microbial air contamination in total joint replacement surgery: results of the GISIO-ISChIA study. J Hosp Infect 2015; 90: 213-219
- 28 Gundel O, Thygesen LC, Gögenur I. et al. Postoperative mortality after a hip fractures over a 15- year period in Denmark: a national register study. Acta Orthop 2020; 91: 58-62
- 29 Wahlsten LR, Palm H, Gislason GH. et al. Sex differences in incidence rate, and temporal changes in surgical management and adverse events after hip fracture surgery in Denmark 1997–2017: a register-based study of 153,058 hip fracture patients. Acta Orthop 2021; 92: 424-430
- 30 Gjertsen JE, Dybvik E, Furnes O. et al. Improved outcome after hip fracture surgery in Norway. Acta Orthop 2017; 88: 505-511
- 31 Cheung ZB, Xiao R, Forsh DA. Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review. Arch Orthop Trauma Surg 2022; 142: 633-640
- 32 Krebs NM, VanWagner MJ, Marchewka T. et al. Tranexamic acid in the treatment of hip fractures: a clinical review. Spartan Med Res J 2019; 3: 7026
- 33 Mundi S, Pindiprolu B, Simunovic N. et al. Similar mortality rates in hip fracture patients over the past 31 years. Acta Orthop 2014; 85: 54-59