Implementation of a Multidisciplinary "Code Hip" Protocol is Associated with Decreased Time to Surgery and Improved Patient Outcomes.

BACKGROUND: The purpose of this study is to report outcomes data based on the implementation of a "Code Hip" protocol, a multidisciplinary approach to the care of fragility hip fracture patients focussing on medical optimization and early operative intervention. We hypothesized that implementation of this protocol would decrease time from presentation to surgical intervention and improve outcomes based on short term post-operative data. METHODS: A retrospective chart review was performed on all patients aged greater than 65 years old with a fragility hip fracture from October 2015 through June 2018. In addition to demographic and patient factors, we recorded time to surgery, type of surgical interventions performed, ability to ambulate in the post-operative period, 90-day post-operative complications and overall hospital cost. RESULTS: There were 114 patients in the pre-Code Hip cohort and 132 patients in the post-Code Hip cohort. Demographic factors were not different between the 2 cohorts. Time from presentation to surgery in the post-Code Hip cohort was shorter at 23.1 ± 16.4 hours versus 33.2 ± 27.2 hours (p < 0.001). 30.3% of patients in the post-Code Hip cohort had at least one post-operative complication compared to 42.1% in the pre-Code Hip cohort (RR = 0.72, CI = 0.51 -1.01, p = 0.05). The post-Code Hip cohort had a significantly lower rate of hospital readmission (p = 0.04), unplanned reoperation (p = 0.02), surgical site infection (p = 0.03), and sepsis (p = 0.05). Total hospital cost per patient decreased from an average of $14,079 +/- $10,305 pre-Code Hip cohort to $11,744 +/- $4,174 per patient in the post-Code Hip cohort (p = 0.02). CONCLUSIONS: Implementation of our Code Hip protocol, which invokes a multidisciplinary approach to the elderly patient with a fragility hip fracture, is associated with shorter times from presentation to surgery, increased ability to ambulate post-operatively, decreased short term post-operative complication, and decreased hospital costs. LEVEL OF EVIDENCE: Therapeutic Level III.

Walking Greater Than 5 Feet After Hip Fracture Surgery Is Associated With Fewer Complications, Including Death.

INTRODUCTION: Hip fractures in the elderly are associated with notable morbidity. The influence of postoperative ambulation on outcomes is not well described. We hypothesized that patients who mobilize faster after surgical intervention would demonstrate fewer postoperative complications. METHODS: A retrospective review was performed on patients with hip fractures from October 2015 through September 2017. All ambulatory patients at least 65 years old (y/o), with a low-energy mechanism of injury, and who underwent surgical treatment were included. Physical therapy notes were used to track postoperative ambulation, and medical records were reviewed for 90-day postoperative complications. RESULTS: One hundred sixty-three patients were included (64 femoral neck, 88 intertrochanteric, and 11 subtrochanteric fractures). Eighty patients had postoperative complication(s). Walking >5 feet by 72 hours postoperatively was associated with decreased morbidity (complication rate: 31% versus 77% (≤5 feet ambulation), P < 0.001). Walking >5 feet by 72 hours postoperatively decreased the likelihood of myocardial infarction (P = 0.003), pneumonia (P = 0.021), intensive care unit admission (P < 0.001), and death or hospice transfer (P < 0.001). DISCUSSION: Ambulating >5 feet within 72 hours postoperatively is associated with a lower postoperative complication rate. To our knowledge, this study is the first to quantify the relationship between postoperative hip fracture mobilization and morbidity and mortality. LEVEL OF EVIDENCE: Prognostic, Level III.

Osteochondral Allograft Transfer for Treatment of Osteochondral Lesions of the Talus: A Systematic Review.

PURPOSE: The purpose of this study is to present a systematic review of the literature regarding the use of fresh bulk osteochondral allograft transfer for treatment of large osteochondral lesions of the talus (OCLT) in an effort to characterize the functional outcomes, complications, and reoperation rates. METHODS: A search of the PubMed, CINAHL, Embase, and Cochrane Databases was performed between January 1, 1990, and March 1, 2016, and included all articles related to outcomes after fresh talar allograft transplantation for OCLT. Inclusion criteria were series (1) published in the English language, (2) using fresh talar allograft, and (3) reporting at least one outcome measure of interest including American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, reoperation rate, and rate of allograft collapse. Weighted averages of outcome data were used. RESULTS: Five studies involving 91 OCLT met the inclusion criteria. The mean age of the cohort was 39 years (range, 15 to 74), and 53% were male. Fresh talar allograft was transplanted into 71 medial, 18 lateral, and 2 central OCLT. At a mean follow-up of 45 ± 3.3 (range, 6 to 91) months, AOFAS scores improved from 48 preoperatively to 80 postoperatively. Pain VAS scores improved from 7.1 preoperatively to 2.7 postoperatively. Twenty-three of the 91 (25%) patients required at least one reoperation, for a total of 28 operations. The most common indications for reoperation were development of moderate to severe osteoarthritis (14%), pain due to hardware (9%), extensive graft collapse (3%), and delayed or nonunion of osteotomy site (1%). Ultimately 12 (13.2%) of the cases were considered failures, with 8 (8.8%) resulting in tibiotalar arthrodesis or ankle replacement. CONCLUSIONS: Fresh bulk allograft transplantation can substantially improve functional status as well as effectively prevent or delay the eventual need for ankle arthrodesis or replacement. However, patients must be carefully selected and counseled on the morbidity of the procedure as well as the high incidence of clinical failure (13%) and need for reoperation (25%) and revision surgery (8.8%). LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.