Listen to Sarah Gill and Andy Marsh discuss posterior malleolar fractures & hip fracture accelerated care.
Listen to Sarah Gill and Andy Marsh discuss posterior malleolar fractures & hip fracture accelerated care.
[00:00:00] Welcome to the January 2021 BJ360 podcast. My name is Sarah Gill and I join you this month from the Queen Elizabeth University Hospital in Glasgow. I'm delighted that you're joining us in this journal club discussion of the BJ360 December edition.
So the plan is to kick off this months podcast with a brief summary of the excellent feature article from the team and Norwich, looking at the investigation of the painful joint arthroplasty, which is well worth a read.
I'm really pleased to introduce my guest this month, Mr. Andy Marsh, and we're going to summarize our highlights from the journal with a few selected papers, before discussing a couple of papers in particular focus, looking at some work we hope and think you'll find interesting to round off our orthopedic literature update.
So the feature in the December edition was the investigation of painful joint arthroplasty. And this is a great piece from Norwich and we're very grateful to them for their input. I think one of the main strengths of the feature is that it really emphasizes the MDT approach that's [00:01:00] required when addressing the painful joint arthroplasty.
The feature very neatly splits causes of pain into intrinsic and extrinsic causes, intrinsic being implants, infection, instability, aseptic loosening, or various soft tissue, impingement issues, and extrinsic being those such as adjacent joint disease, spinal pathology, vascular disease, malignancy, or metabolic bone disease.
I think the feature, when you read it through, it provides a really good roadmap and discusses sequentially the evidence for clinical radiological, microbiological, and biochemical workup of these clinical problems.
It's a really thorough update on this common clinical problem. And I think it would be of interest to primary and revision arthroplasty surgeons and also trainees of all grades who will be exposed and involved in the presentation and workup of these patients. So do give it a read and get in touch with us and let us know your thoughts.
Now the original plan for this month was a trauma [00:02:00] update from the OTS. But as fails are increasingly common at the moment, plans have had to be flexible. And I look forward to catching up with the OTS guys later in the year at the rescheduled meeting, but it does give us the opportunity to have someone with us this month who I've been looking forward to having on as a guest. So it's actually all worked out pretty well.
Andy Marsh is one of my pelvic and acetabular colleagues here at the Queen Elizabeth, although I somehow feel like that comparison is slightly flattering to me. Andys fellowship trained in revision hips with dominant meek, lower limb trauma at the Royal Melbourne with Andrew Oppy and PNA trauma with Pete Bates and Paul Copan at the Royal London.
So his depth and breadth of practice and clarity of thought means we're very lucky to have him here in the units. And I'm really pleased he's offering up his thoughts to our listenership today. So, Andy, thank you very much for being strong armed into doing this.
Thank you very much, Sarah. It's great to be invited.
Great. So on with the sort of Roundup and highlights of some papers from this month.
So the first paper I picked out that I wanted to [00:03:00] discuss this month was in fact the results of the SWIFFT study from Leicester. So this is the scaphoid waist internal fixation for treatment study. And this was published at the Lancet, which is always of note and it focuses on exactly that - the management of scaphoid waist fractures and asked the question, how should we manage these? Should we be fixing them? Should we be managing them in a cast?
So this is a huge NIHR funded study and includes the results of 439 participants from 31 centers. And the inclusion criteria clear bi-cortical fracture on plain radiographs. And these patients were then randomized evenly between fixation and cast immobilization. So the big headline of this study is that in the primary outcome, which was patient-related wrist evaluation at one year, there were no differences between those treated with surgery and those treated in a cast. Complications wise, the rates between the two groups were very similar. But the complication type was fairly classic of the arm of the study they were in.
So with the [00:04:00] surgical group, it was more likely to be infection or nerve injury as compared to the cast treatment group where it was likely to be stiffness. So this is a big study and the conclusion of the authors was that any waist of scaphoid fractures displaced by two millimeters or less should be treated in cast immobilization.
They accept that there will be an incidence of non-union but they propose that that could be treated later on.
So as we have said big study, powerful journal that it is published in and as always with these pragmatic studies, helpful for broad brush strokes. One of the things I was going to highlight Andy is in reading this paper, it recruited over 400 patients but it was a potential there were over a thousand patients, who had a waist of scaphoid fracture that could have been included in the study. So it's not by all means all patients in all waist of scaphoid fractures.
So someone who sees them in the general clinic, any other questions that you'd want from a [00:05:00] study like this to help you?
Well, I think as mentioned, Sarah, it's very helpful for guiding broadly the management of scaphoid fractures, but it's important to also, you know, thinking about the individual patients and one patient often presents in the fracture clinic will be the manual worker who has a diagnosed scaphoid fracture and then is keen to get back to work for employment and financial reasons.
So therefore it doesn't necessarily help as much for that individual patient who may lose out from those aspects because of immobilization and the cast for a period of time who then developed some nonunion. And in that type of patient, you may be more keen for them to be fixed in an early situation.
Yeah. So helpful in terms of patients where you have the choice. This is helpful in supporting non operative. Equally, there are patients that are going to benefit potentially from earlier fixation.
Yes. Yeah, definitely.
So the next [00:06:00] paper I wanted to mention was this paper from Leeds, looking at time to surgery for open injuries, in the hand and the risk of surgical site infection. And this was published in the journal of hand surgery, European volume.
And what really drew my interest to this is that this is a clinical , uh, challenge uh, and especially recently, I think, you know, when there's been real time on , , um, real pressure rather on theater time . , um, And maybe these injuries are things that have potentially waited a little bit longer over the last 10 months than we previously would have been comfortable with.
Um, So I think some evidence on this topic is very welcome. Uh, The cohort study is , uh, taken from two tertiary hand centers and it looked at nearly a thousand patients. Uh, Inclusion criteria was patients over 16 with traumatic unilateral hand injuries, distilled to the wrist crease, and they collected this over a two year period.
They excluded any patients who presented with infection, ischemic digits , um, or those requiring reimplantation. The primary outcome measure they [00:07:00] looked at was reoperation within 28 days of primary surgery for infection. Uh,
The median time from injury to assessment was three and a half hours. And the median time from injury to surgery was 20 hours with a range of four to 90 hours.
Um, So the take home message here is that they've identified 41 patients who develop an infection after primary surgery, but when comparing those that did, and those that did not develop an infection, there was no difference in time to surgery between those groups. In fact, the only preoperative predictor of subsequent infection was traumatic tissue loss, not contamination, not use of antibiotics or timing thereof, and no patient factors, just traumatic tissue loss.
Uh, So the conclusion drawn by the authors here was the delay for primary slash definitive treatment in a tertiary hand unit is justifiable um, and what I'm taking away from the paper is that a delay of one to two days to allow the case to be done by a hands [00:08:00] colleague, which might increase the chances of A) being the definitive procedure rather than stage is , um, B) uh, the chance of getting it right first time for the patient , uh, is probably justifiable and it probably even more so in the contact in the context of , uh, traumatic skin loss.
So , um, yeah Andy, talk to me about the papers that you've picked out for us to look at.
Yeah, so I picked out papers as well, Sarah. The first one was really looking at optimizing imaging protocols, following acetabular fracture fixation, right. And this was a study from Los Angeles , um, in the journal of orthopedic trauma.
Um, This study really looked at , um, cadaveric specimens and what they were aiming to do was , um, look at , um, whether lower dose CT scans post-operatively. Um, could be used for assessing fracture fixation rather than using a higher standard dose that is commonly used in practice at the moment.
Okay. So that was the focus of can we use a lower dose [00:09:00] CT rather than a higher?
Yeah. Okay.
So he looks at , um, eight cadaveric specimens or 16 hips , um, altogether. They created posterior wall acetabular fractures. They then , um, reduced and fixed them to varying degrees - one anatomically, others with varying degrees of step and gap displacement, right. And using standard posterior wall fixation techniques under standard plate. Um,
A number of trauma surgeons then assess the postoperative CTs that were done. Each specimen had a standard dose CT, an intermediate does CT and a low-dose CT protocol.
Right.
The other thing to say about , um, the fracture fixation was that he randomly placed intraarticular screws as well in some of the specimens.
I like to do that as well.
Yeah. Yeah. You threw me off a little bit there, Sarah. I'm gonna have to look back at some of your post-operative images as well. Um,
So yeah, so having done that , um, [00:10:00] the, the conclusion that they made was essentially that there was not any significant , uh, difference in , um, assessment.
Between the different , uh, doses of CT used and the assessment of displacement or interest articular screw penetration. However, when you actually look at the results of it, probably the more interesting thing was essentially how bad it was or how difficult it was to assess the fracture reduction. When you looked at it it varied. They tried to categorize the reduction as either into , uh, desired and perfect reduction, imperfect reduction, which was a few millimeters displaced or a poor reduction. And only between 28% and 58% of the specimens were correctly identified to have that.
Right.
So, so pretty poor results when you're looking at that. So regardless of dose, what your interpretation of those CTS actually did not correlate very well with what they know that they had done to those specimens in the lab.
Yeah, exactly. And even [00:11:00] when you look at that in more detail, if you look at the inter observer reliability, it was poor. But if you look at the intraobserver reliabilit y aty , uh, at best, it was fair.
This probably depends on whether you ask someone on a Monday when they're feeling quite upbeat about stuff, what they think their CT scan looks like compared to Friday morning when you're more likely to get a realistic , uh, appraisal of how good you reduction was.
Exactly. So you know, for yourself Sarah, you may have to figure out specimens on a Monday.
Yes, that's why I always show them on a Monday. And then I just go through the department to find someone who says, yeah, that looks all right. And then we're done.
Okay. Interesting. So how would you apply that to clinical practice? Because what that is saying to me is that CT scans are not the be-all and end-all in terms of , um, postoperative , uh, assessments of fracture reductions.
In clinical practice it really does question, should you use a CT scan post-operatively regardless of the dose use? And I think for myself , um, the way that I would [00:12:00] apply it is that I wouldn't routinely use a CT scan for assessment of , um, posterior wall fractures or acetabular fractures. I think the more important thing to be thinking about is assessing it intraoperatively. And the other advantage there is that you're much more likely to be able to then change it there and then. Rather than having to rely on a postoperative CT scan, which you may misinterpret.
Is there any patients that you would CT , um, post acetabular fracture?
I think the most helpful ones are probably the more complex fractures. Yeah. Many prognostic, as I said for the patient, I think it's important to inform them , um, whether it is. As you know, a reasonably good reduction, but also could be helpful educationally in doing that.
So go for it. What was your second paper?
Yeah, so I think you'd be very interested in this one, Sarah. We've been excited by this because it is actually a COVID-related paper. Uh,
I haven't seen enough of those, like tell me more. Um,
Well, so this paper really was the London experience from [00:13:00] COVID-19 and hip fractures. And obviously there's been lots and lots of COVID papers out there, but the main reasons why I've picked this is because , um, compared to some injuries, hip fractures are one of the injuries that during the first wave of COVID the management could not change . they still undergo emergency management that needs to take place.
Also , um, as reported , um, by one of the studies that collaborative , uh, Scottish study that you were involved with , um, the rate of hip fractures during the first wave , uh, certainly in Scotland, if anything increased a little bit and other studies have shown that the rate during their first waves has at least stayed the same.
So this paper was a multicenter cohort study um, during the first wave of COVID in London. It looked at 442 patients , um, and really looked at the outcomes , um, following hip fracture surgery for COVID positive patients compared to those that were COVID negative. So they had 340 COVID-negative patients in the [00:14:00] cohort and 82 COVID-positive patients.
And they looked at 30-day mortality and other complications associated with this, um, as well as things like critical care admission and length of hospital stay. So these are a group of , um, neck of femur fracture patients with COVID compared to neck of femur fracture patients without COVID.
Exactly, exactly . , uh, . What they found, um, not surprisingly, although it's very interesting, they reported this: increasing mortality in the COVID-positive patients undergo hip fracture surgery, and that was 30% compared to 10%. They also found increased complications. Most of the complications being either cardio-respiratory from *inaudible* events or multiorgan dysfunction. And again, that was very high, 89% versus 35%.
In terms of things like critical care admission, again, as expected, it would be higher in the COVID-positive patients in 61% versus [00:15:00] 18% with 10% of the COVID-positive patients being admitted to ITU.
So, yeah, so the numbers you're talking about here are a bit eye-watering in terms of, you know, is that a 90% major complication rates with COVID-positive neck of femur fracture patients, and a mortality rate of 36%.
Yeah. So very high, um, and in addition to that , um, length of hospital stay, which was doubled , um, 14 days compared to seven days, they also looked at some factors which would account for the complications and in particular smoking was one of the risk factors as would be expected. And the other thing would be multiple comorbidities. So having three or more major comorbidities.
I think my question would be, did you get any flavor either from the study or yourself, are these patients who are suffering from complications because of COVID as an illness or are they suffering from having a neck of femur fracture during the time of COVID when all of our resources are [00:16:00] so stretched?
Yeah, and it's interesting. And there may be a little bit of both in there, but I guess the first thing to say is that, um, most likely these are related more to the disease itself. Okay. Um, so the reason why I say that is if you look at other papers, so for example, if you look at , um, one of the more recent , uh, medical papers from the office of national statistics in England , , , um, I think this is a combination between Leicester diabetes center and UCL. They reported that patients who haven't had surgery who have been , um, COVID-positive, the readmission rate to hospital within the next six months was 30% and the death rate was 12%. And again, the complications associated with the readmission- the reason for readmission was really cardiorespiratory and thromboembolic events.
You're right. We're entering the second wave. These things are very relevant. And actually this is an and I mean, obviously I'm floundering now because I can't believe you read a non-orthopedic paper, but in fact, this is the *inaudible* of COVID, not just the environment that we're in [00:17:00] at the moment.
Exactly. And I think my take home from this and the reason why it's interesting is not so much um, just the findings, which some people would find to some extent, unsurprising . , um, It's really the fact that , um, with those findings important that , uh, to foreign patients with the consent process to inform relatives, it may help to some degree with optimization of care, but also with the peri-operative support, the fact that a lot of patients are going to have these problems may need critical care support. The fact that the length of stay is going to be so long afterwards as well. And that has implications to the service for hip fractures, but also to the rehabilitation for the medicine, for the elderly team as well.
Okay, so having , um, done a sort of a, well, not quite a whistle stop tour actually there's loads takeaway from that um, . . , um, through the rest of the journal, the paper that I've picked to talk about this month, Andy is one from , uh, Amsterdam. It's a foot and ankle paper. Uh, The lead author is Blom and it's published in the BJJ in fact , um, and the [00:18:00] title is Posterior malleolar ankle fractures: predictors of outcome. So I'm going to try and summarize what is a fairly monster paper, but I think with some really interesting take-home points , um, .
So this paper really focuses on the morphology of posterior malleolar ankle fractures um, It talks about the inherent issues of reduction or malreduction with these injuries and it uses the foot and ankle outcome scores , um, as the primary outcome. And it talks about those in the context of fracture morphology. And so the reason I picked the paper, Andy, was , um, not really just because of its findings or from honest um, but it was more broadly , um, that it adds to our literacy of posterior malleolar ankle fractures, which is, I think is definitely a topic of increasing interest in foot and ankle trauma.
Yeah. Uh, y
You know, I think it really strengthens the ongoing discourse , um, that not all posterior malleolar ankle fractures are the same , uh, and this trend towards appreciating the morphology and fragments specific fixation.
So focusing on the paper and [00:19:00] kind of to try and sort of summarize it in a nutshell, this paper presents a retrospective review of what was prospectively collected data of 70 patients with , uh, posterior malleolar ankle fractures. These patients underwent fixation , um, and they were actually, these 70 patients were taken from a larger , um, study cohort, the EF3X ankle fracture trial, and, what that was actually , um, doing was collecting data to examine the use of 3d versus 2d for *inaudible* intraoperatively. But the authors of that were able to then , um, siphon these 70 off because these 70 patients had , um, posterior mal fractures. Um, So that's from a larger cohort of , uh, about 180 patients.
All of these patients were treated in the same level one trauma center. The mean age of the patients was 47. There was about 50:50 male to female ratio and the , uh, it was mainly low energy mechanisms of injury. Um,
So these ankle fractures were managed operatively, either with , um, a type of direct [00:20:00] fixation of the posterior mal, such as an anti glide plate, and that might be to one fragment or in the case of the posterior mal fractures that have a separate posterolateral and posteromedial fracture, maybe two separate anti glides, an AP screw, or even a PA screw. So they were all direct uh, fixations of these posterior mal fractures , um, or they are treated with an indirect fixation. That's basically a syndesmosis screw and either a single or a double. uh
Interestingly , um, the authors don't present any sub analysis , um, that was done by type of fixation. Um, They've stayed true to their word and they're really focused on the fracture morphology rather than trying to start compare one type of fixation versus another.
Um, The morphology was classified , um, using the Haraguchi classification one to three. And I'm going to come onto this later in , uh, the discussion , um, and the fracture reduction was assessed postoperatively using a CT scan. So all of these patients were CT scans post-op and the measurements they made , um, when examining fracture reduction , um, were either defined as a classic , um, type of [00:21:00] measurement, such as residual , um, fracture gap post-operatively or an articular stat, which I think is something that, you know, we're used to looking at in terms of , uh, ankle fracture reduction as , uh, as a , uh, quantifier of reduction , um, or they define these new contemporary , uh, measurements, which included the total surface area of any step off at the articular surface, the 3d rotational displacement of these uh, fracture fragments , , um, ,a step in the fibula notch or , um, quality of syndesmotic reduction, which they made binary. It was either reduced well or not reduced.
So is that making sense so far in terms of what the study looked like?
Yeah, no, it makes clear sense there Sarah.
And so wha were the good things about this study? ? ? , um, First of all, findings were based on postoperative CT scans, so that , um, I think immediately , uh, is very helpful uh, and this allowed for real rigor and detailed analysis, which honestly is almost a little bit mind-boggling when you first read the paper, um, but the authors definitely have to be commended on what was a [00:22:00] very thorough analysis of these , uh, ankle fractures. . , um,
They had a two year follow-up for these patients. So this is really , um, I think uh, , uh, yeah a very good length of followup and does tell you something about how these fractures behave. And the fourth one that I'm going to say is a good thing, is this heterogeneity of fixation load. Um, I can see how that could look like an inconsistency, cause you might read it and say, well, I would never do that for that type of fracture um, but I think if you're looking at the effect of morphology on outcome, I think by allowing , um, you know, certain choice in terms of how to fix, then you remove that as a type of bias, as a bias, because you're not saying, Oh, actually the results of this type of fixation are this, you really are saying the results of this fracture, morphology , um, are this.
In terms of limitations, I think just a couple of things , um, that you probably have to manage - that it's not tiny, but , um, 70 patients isn't huge. Um , uh, And it's not statistically powered. Um, And it's a single center. So again, we can't be sure it's reproducible, but again, I stress that this is a paper that's looking [00:23:00] at the effect of morphology rather than their intervention.
Yeah. So I've tried to highlight a few points for discussion here and the first one, I'll loop back to this, is that I think this paper by its very existence calls for us to get on board and embrace this greater understanding of , uh, posterior mal fractures. Um, So I don't know about you, but I spent my entire training and my , um, practice , uh, you know, in , uh, ankle trauma so far sort of really extolling the virtues of *inaudible* Hanson. You know, I think it gives you a good working understanding of ankle fractures and fixation methods. Um, but , um, I'm probably now having to just accept that it isn't, it can't do everything and it isn't everything um, and I think this paper um, adds to that literacy. And I think it goes well with the work from Liverpool that we're seeing in terms of promoting interest and increasing knowledge in , uh, posterior mal ankle fractures.
So the second point I'd make is that , um, the results rely on an understanding of Haraguchis classification. And I just want to highlight that [00:24:00] , um, to the listener, because it's different to the Mason classification. So, you know, in the UK, we've spoken about this a lot over the last 12 months. Um,
And finally just before moving on to the take home message from the paper to, again, reassure us that we really can vanish fixation method as a bias, the results the authors found. And I thought this was really interesting actually , um, that there were no significant differences in the quality of reduction between fixation methods. You know, it'd be that an anti-glide plate , uh, an AP screw or a PA screw. They found that the reduction was , um, equally good across the board.
Um, So now what can we take from the findings? So the first one is that in the posterolateral shear fractures of the posterior malleolus , um, there were two predictors of poor outcome, and that was residual intraarticular step-off and poor quality of syndesmotic reduction. They were both , um, independently , uh, associated with a poor reduction in those patients, which again, kind of makes sense, because we think with those big shear fractures, we need to restore articular congruency. [00:25:00]
Uh, The second one , uh, is that in these posterior malleolus fractures , um, with posterolateral and posteromedial fragments , um, these fractures did worse across the board , uh, on the foot & ankle outcome scores , um, compared to posterolateral, the rim type that we're going to come on to. So there's definitely something about this pattern that involves the posteromedial , uh, section of the tibia, that confers a poor outcome. , um, And in these fractures , Um, actually only step off at the fibular notch n , um, predictive of poor outcome, which I thought was really interesting, cause you're saying that there's something about the posteromedial l , uh, involvement that makes it poor, but actually what they found was it was the step off at the notch in these fractures, in the fibular notch that caused , um, *inaudible* was that was associated with that outcome. I suppose you're saying that maybe they're more inherently difficult to reduce is my wonder in these fractures.
So the final, the third , uh, type , um, they talked about was this rim type avulsion fractures of the [00:26:00] PITFL. And in these fractures quality of syndesmotic reduction was a predictor of , uh, foot and ankle outcome scores, which isn't really surprising given that these are very small fragments. You're not likely going to see an associated significant fracture gap or 3D displacement. And they are often going to be managed with an indirect fixation method, like a syndesmosis screw. So it's really quality , uh, of your syndesmotic reduction in these fractures, that's the most important.
So to summarize , uh, the take home messages from this paper, for me: 1) embrace the fragment specific discussion of posterior mal fractures. They're just, they're not all the same. And I've just got to go over that. Um, In posterolateral shear fractures , um, you must aim to anatomically reduce the articular surface and the syndesmosis - it's key. In fractures involving the posteromedial fragments, counsel patients of the associated poorer prognosis and focus on restoring the fibular notch congruency. And in the third time, the rim avulsion fractures quality of syndesmotic [00:27:00] reduction is key interoperatively.
It's a really interesting paper. I guess the question I'd like to ask is really simple - um, if you look at the BOA ankle fracture guideline from 2016, they recommend CT scanning for more complex ankle injuries. With regards to this paper and other papers that have come up more recently, looking more at , uh, posterior malleolar morphology, would it be recommended to CT scan all ankle fractures that have a posterior malleolar configuration to it ?
Yeah, Andy, you know, that's a really key thing to come out of um, the discussion of this paper, because it was one of their key conclusions was all posterior mal fractures should be CT scanned. It's also a conclusion that Lyndon Mason came to in his Ontarian lecture last year. And in fact, he's kind of answered the question for us because he looked at the papers around imaging and posterior malleolar fractures and found that the sensitivity of plain radiographs alone was only about 20%. And that in all of the studies, [00:28:00] CT scan changed the optimum management of these fractures and it's particularly the posterior medial, the postomedial fragments that are not well visualized on plain x-rays. So essentially the message is yes, if there's posterior mal fracture, the CT scan pre-op.
Okay, so over to you Andy and I think that paper that you've picked , uh, for discussion is again on the trauma theme, but different we're moving more, essentially from foot and ankle on to hips. Tell us about this , um , uh, big paper actually on hip fractures.
Yeah. This is another massive treat because this is the second paper that was published in the Lancet that is featured in the BJ360. Yeah, this is the thing that some people only dream over really. So this was a HIP ATTACK study and HIP ATTACK, I believe stood for hip fracture, accelerated treatment track study, and it was based in Canada and funded in Canada, but it was an international multicenter randomized [00:29:00] control trial. It involves 69 hospitals in 17 countries. And it looked at an accelerated surgery pathway for hip fractures patients versus standard care. And what they aim to do is assess whether this accelerated pathway could really reduce mortality for these patients, as well as major complications.
It was based on previous observational studies , uh, proceeded by a pilot study. There was power analysis. Um, in order to calculate sample size enrollment, extremely well-designed trial, it also had rigorous checking regimes, monitoring data centrally for consistency, looking at statistical monitoring and also at hospital site monitoring as well. The outcome assessors were also masked to the treatment group.
Patients included in this study were representative for the typical neck of femur fracture population. There were low energy hip fractures that were included. The age was over 45, but the mean [00:30:00] age for patients with 79 years, which would be typical again for this group. 33% of patients had assistance with activities of daily living. 20% were nursing home residents, 20% had dementia and the fracture type again would be typical of what you would see at your average trauma meeting with approximately a 50/50 split of intracapsular neck of femurs and extracapsular neck of femurs.
The exclusion criteria again were very appropriate. They excluded periprosthetic fractures, bilateral hip fractures, open fractures and , uh, emergency surgery that was carried out for other reasons, such as a subdural hematoma.
So before going on to talk about the results, um, I think it's important just to talk about , uh, the different pathways. The accelerated surgery group, the aim here was really to facilitate surgery for the hip fracture patients as quickly as possible, and based on their previous observational studies and pilot study, it was aimed to try and , um, have the surgical operations performed [00:31:00] by six hours.
Now, what that meant and what they u , uh, put into place to this study was that patients randomized to this group had medical assessment and clearance for surgery by physicians who were readily available to rapidly review these patients.
The patients that were operated on were also prioritized for theater on the next available trauma slot. And that meant that elective patients or non-emergent trauma patients , um, were therefore postponed in favour of these patients.
In addition to this, to avoid cancellation for the patients and in particular, the elective patients, um, in place was an extra operating slot at the end of the day to accommodate for these patients to prevent cancellation.
Okay. So practically this is a huge undertaking. These patients are put in the hospital and they're being medically worked up and getting to theater within six hours so treated like an orthopedic emergency, and other patients are being displaced on two lists later or additional lists in order to make way for that.
[00:32:00] Exactly. Exactly. And when you look at the standard care group, it would be similar for standard care in most hospitals. Okay. The big difference really being that their medical assessment and clearance for theater occurred according to your local standard practice. So there was no rapid assessment medically for these patients to optimize them for theater.
Okay.
So when looking at the results from this study , um, the 2,970 patients were enrolled into the study and following random allocation, 1,487 patients were randomized to the accelerated care pathway, 1,483 patients randomized to the standard care pathway. Well, there were only seven patients , um, in the accelerated care pathway were lost to follow-up. Eight patients in the standard pathway. So the lost to followup was less than 1%. Very, very impressive.
Looking at the baseline characteristics between the groups which were extensively analyzed there was no significant [00:33:00] difference. Okay. The big difference was really as expected in median time to surgery for the hip fracture patients. In the accelerated group this was a median time of six hours. And in the standard care group, this was a medium time of 24 hours. And this was statistically significant with an absolute difference of 18 hours.
Yeah. So they really did achieve what they set out to do. They really did provide an accelerated service for that group of patients.
Yeah, exactly. Looking at the outcomes. Um, there was no difference statistically, in terms of mortality between the two groups. So the mortality was 9% in accelerated group versus 10% in the standard of care group. Right. Similarly, major complications , um, did not show any significant difference between the two pathways with 22% in both groups.
However, other complications such as delirium, infection without sepsis, urinary tract infection , um, was less than the accelerated [00:34:00] group. Um, So similarly , um, time to mobilization um, following randomization was less in the accelerated group with 24 hours compared to 46 hours in the standardized care group. And also meantime to discharge with less than accelerated group as well, 10 days versus 11 days.
Other outcomes that they looked at were orthopedically related outcomes. And again, there was no difference between the two groups specifically. They looked at reoperation rate, dislocation implant failure, periprosthetic fracture and surgical site infection um, and there was no difference between the two groups as well.
So in terms of, you mentioned that one of the statistical differences was the time to discharge, but the actual difference in that was a day. Is that right?
Yeah, one day. And when you look at that , Um, I mean, as I said, this was a very , um, robust study and the statistics , uh, were very robust as well. The only thing that I was [00:35:00] interested when I looked at that was that it looked at mean time to discharge. And as we know, in a frail elderly population, often there'll be variability in discharge. And often in some patients, it can be prolonged for a number of different reasons. And when you... it's just interesting looking at mean, because when you look at mean, you do wonder whether a delayed discharge that's prolonged for a long time could skew the results, particularly for the mean, and I would be interested to look at the median as well to find out if that was also statistically significant.
Yeah. That, yes, that does make sense.
Yeah. So again, that kind of goes hand in hand because if you're getting your surgery earlier rliera , Um, six hours versus 24 hours, you're going to go home earlier. So it's a kind of it's proportional. Does that make sense? You're literally shifting the events in that patient's care a day further forward, and that includes surgery and then discharged.
Yeah, exactly. And I guess that's what they're trying to aim with the accelerated cure pathway.
So, you know, overall you have to command the authors [00:36:00] that have , um, designed the study. It is extremely well-designed. Um, It's obviously , uh, an international multicenter randomized controlled trial that's as I've mentioned, has been rigorously done with a low loss to follow-up.
It also , um, should be commanded as they've looked at , uh, changes to patients pathways and service provision, rather than just looking at a single treatment modality as well. Yeah. Um,
The authors do outline the limitations to their study, but the comments that I would really like to make, thinking about the feasibility of implementing that to your own hospital , um, and trying to accommodate an accelerated pathway for these patients, particularly when some of the main outcomes really aren't showing a significant difference between standard care anyway.
In particular, if you're looking at the success rate to care pathway, it did require a lot of flexibility of your theater time. Um, Particularly looking at prioritizing these patients over either elective patients or other trauma patients. And this was [00:37:00] highlighted in the study. When you look overall at the results, there was just under 8,000 patients eligible for the trial. But 25% of them were not enrolled. And the reason they were not enrolled was because they could not accommodate them in the operating theater, or there was no surgeon available to do the case.
Right. Okay. So actually there's a large number of patients that they didn't roll because actually that huge feasibility to short term flexibility wasn't available that day.
Exactly, exactly. And also, you know , um, in practices for everyone when you're trying to change theater lists. Even if you can accommodate for that, the efficiency of that list also , um, often goes down when you're trying to do that and change cases , um, you know from what was planned initially.
Yeah. This is something, you know, I think comes up a lot and I've , um, you know, we've talked about before the two competing factors in any theater list , uh, - efficiency and flexibility, and they are at opposite ends. I dont think you can please both. Um, So as you say, my, my rule would be that this flexibility actually leads to [00:38:00] potentially fewer cases being done and those other cases might not be neck of femur fractures.
Yeah, definitely. And that's something that you see quite common when you change the list. The other things to think about is that not all patients in the neck of femur population will be able to be optimized anyway. Yeah. By definition, these patients have significant comorbidities and even , um, when you're trying to optimize them, some of them will still need to have treatment that then will lead to delayed surgery anyway.
And again, that was highlighted in the paper. Um, There's at least a 200 to 250 patients , um, which were not enrolled in the study because they were classified as physician declined. Now I'm presuming that means that those patients were not optimized. Not that the physician declined to actually go and see them.But you can take what you will from that statement.
I guess the other thing to say about this was that the study was really taking place in normal standard working hours.
[00:39:00] Right.
So they did not look at patients out of hours and obviously a proportion of neck of femur fracture patients will obviously present in the evening time or overnight. And so the implications of trying to , um, provide an accelerated care pathway is obviously going to be more difficult in the out of hours t of houu , um, which wasn't in this study.
Oh, that's interesting. Okay. So. Yeah, that does make a big difference actually to the applicability to try and, you know, as you say, trying to apply this to our practice here , um, because these are all patients recruited from in hours. These are not your neck of femur fractures that kinda coming in at 10:00 AM. And therefore would have to wait a minimum of 10 hours to go to theater anyway. Yeah. Yeah. Okay.
So overall, the take home message from this paper really was that an accelerated care pathway for neck of femur fractures, trying to provide surgery within a six-hour periods , um, did not significantly change mortality or major complications for these patients. However, [00:40:00] the paper did show improvement in delirium, urinary tract infections, and also allowed earlier weight bearing an earlier mobilization and may also reduce length of stay looking at the paper. And the authors in that paper are going on to the economic analysis to try and see whether length of stay , um, and the cost effectiveness of this may be helpful and therefore give further weight to the accelerated care pathway.
Yeah, a really ambitious paper, as you say , um, very rigorous and , uh, grateful for your efforts in going through that and picking out the , uh, the key messages there. So thank you, Andy.
No worries.
That brings us the end of this episode and a big thank you from the team at 360, to Andy Marsh for being such a great guest. I'm really looking forward to February's podcasts because listeners from December will remember that the team is growing and Tim Coughlin, upper limb specialist will be hosting from Queens medical center.
You can subscribe to the podcast on Spotify, Google, and Apple, and follow us on Twitter at [00:41:00] Bone & Joint 360 for more updates.