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Mortality following distal femur fractures versus proximal femur fractures in elderly population: The impact of best practice tariff.Background and objectives: The mortality after hip, proximal femur, fractures in elderly patients has steadily declined in the last decade in the United Kingdom as a result of implementing of multiple protocols focusing on prompt multidisciplinary pre- and post-operative optimization and reducing time to surgery. The pinnacle of these protocols is the development of the best practice tariff as an incentive program for hospitals that meet set criteria by the National Health Service (NHS) England in managing these injuries. Until the time of writing this paper, there was no parallel program for the management of fractures involving distal femur in the elderly. The aim of this study is to evaluate the outcomes of distal femur fractures in elderly patients against proximal femur fractures regarding post-injury mortality, the prevalence of surgical treatment and time delay till surgery. Methods: A retrospective study of all patients above the age of 60 admitted to Queens Hospital Burton between 2010 and 2014 with fractures involving distal end of the femur. Patient data were assessed for demographic criteria, co-morbidities as per Charleston Comorbidities Index, type of management, time-lapse before surgery and 30-day, six-month and one-year mortality. Results were compared to an age-matched control group of patients with proximal femur fractures randomly selected during the same time window. Results: The main demographic criteria such as age, gender, and Charleston Comorbidities Index were similar in both groups. There were more patients treated non-operatively in the distal femur group than in the proximal femur group (15% vs 4%). Time to surgery was statistically significantly longer in distal femur group compared to the proximal femur (49.130 hours vs 34.075 hours, P = 0.041). The mortality in distal femur group was higher at all times (9.68% at 30 days, 20.32% at six months and 34.41% at one year) when compared to that in the proximal femur group (6.99% at 30 days, 14.52% at six months, 21.51% at one year). Conclusion: The distal femoral fractures showed higher mortality at 30 days, six months and one year compared to the proximal femur group. This could be partly influenced by the implementation of best practice tariff in the proximal femur fracture group reflected in less time to surgery, pre- and post-operative multidisciplinary approach and more frequent operative management.
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One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture : a meta-analysis of randomized controlled trials.AIMS: There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. METHODS: A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. RESULTS: Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges' g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. CONCLUSION: We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953-962.
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Predicting fracture risk in osteoporosis: the use of fracture prediction tools in an osteoporosis clinic population.BACKGROUND: In the UK, the National Institute for Health and Care Excellence recommends either fracture risk assessment tool (FRAX) or QFracture to estimate the 10 year fracture risk of individuals. However, it is not known how these tools compare in determining risk and subsequent treatment using set intervention thresholds or guidelines. METHODS: The 10 year major osteoporotic (MO) and hip (HI) fracture risks were calculated for 100 women attending osteoporosis clinic in 2010 using FRAX and QFracture, and subsequent agreement to treatment between the tools was looked at using National Osteoporosis Foundation and National Bone Health Alliance thresholds (FRAX-20/3 and QFracture 20/3). We also looked at using these thresholds for QFracture and comparing them with the National Osteoporosis Guideline Group (NOGG) guidelines for FRAX (FRAX-NOGG). RESULTS: The 10 year risk for MO fracture for FRAX was 17.0% (IQR 10.8-24.0) and that of QFracture was 15.8% (IQR 9.5-27.7) (p=0.732). The 10 year risk for HI fracture for FRAX was 5.0% (IQR 2.1-8.9) and that of QFracture was 8.1% (IQR 2.5-21.6) (p<0.001). The agreement between FRAX-20/3 and QFracture-20/3 was greater than the agreement between FRAX-20/3 and FRAX-NOGG or QFracture-20/3 and FRAX-NOGG. CONCLUSIONS: The calculated 10 year risk for MO fracture between FRAX and QFracture was similar, whereas that of HI fracture was significantly different. The agreement to treatment between QFracture-20/3 and FRAX-NOGG was only 45%. Treatment decisions can differ depending on the fracture calculation tool used when coupled with certain intervention thresholds or guidelines.
