Aims Patients with a hip fracture are treated by surgeons at various stages of training, under different levels of supervision. However, it is unclear whether their experience and the level of supervision are associated with patient outcomes. The aim of this study was to investigate the relationship between operating surgeon experience and level of supervision, and the patients' subsequent quality of life (QoL), mortality, and complications after surgery for a hip fracture. Methods A multicentre, prospective cohort study of patients aged 60 years and older with a hip fracture in the UK. Primary exposure was operating surgeon grade and level of supervision. Outcomes were health-related quality of life (HRQoL; EuroQol five-dimension five-level questionnaire (EQ-5D-5L)), mortality, and complications at four months. Linear and Cox proportional hazards regression models were fitted to assess the relationship between operating surgeon grade and level of supervision, and HRQoL, mortality, and complications. Results Among 24,523 patients with a hip fracture, there were 12,702 consultant-performed and 11,365 resident-performed operations. Operations performed by supervised residents had better recovery of EQ-5D-5L (mean difference (MD) 0.02, 95% CI 0.01 to 0.03; p < 0.001), a similar risk of mortality (HR 0.92, 95% CI 0.84 to 1.01; p = 0.083), but higher risks of reoperation (HR 1.29, 95% CI 1.06 to 1.57; p = 0.009), blood transfusion (HR 1.44, 95% CI 1.28 to 1.62; p < 0.001), acute kidney injury (HR 1.72, 95% CI 1.46 to 2.04; p < 0.001), lower respiratory tract infection (HR 1.22, 95% CI 1.10 to 1.35; p < 0.001), cerebrovascular accident (HR 1.98, 95% CI 1.33 to 2.95, p < 0.001), and myocardial infarction (HR 1.91, 95% CI 1.33 to 2.74; p < 0.001), compared with operations performed by consultants. Operations performed by unsupervised residents had better recovery of EQ-5D-5L (MD 0.02, 95% CI 0.00 to 0.03; p = 0.008), a similar risk of mortality (HR 0.92, 95% CI 0.81 to 1.06; p = 0.260), but a higher risk of blood transfusion (HR 1.54, 95% CI 1.33 to 1.80; p < 0.001) compared with operations performed by consultants. Conclusion Operations performed by residents were associated with a better recovery of QoL, similar mortality, but slightly more complications compared with consultants. This highlights the need for tailored supervision and structured training to optimize outcomes and ensure patient safety.

Aims:The use of cephalomedullary nails for the fixation of extracapsular hip fractures has increased in recent years, but high-quality evidence to guide surgical decision-making between long and short cephalomedullary nails is lacking. The aim of this study was to compare the quality of life (QoL) and the risks of mortality and complications in patients treated with long and short cephalomedullary nails. Methods:The World Hip Trauma Evaluation (WHiTE) study was a multicentre, prospective cohort study that collected data from patients aged ≥ 60 years who received operative treatment for their hip fracture. Patients were followed up for 120 days after surgery. The primary variable of interest was cephalomedullary nail type (long or short). The primary outcome was health-related QoL (EuroQol five-dimension five-level questionnaire (EQ-5D-5L)). The secondary outcomes were mortality and complications. Linear and Cox proportional hazards regression models were fitted to assess the relationship between cephalomedullary nail type, EQ-5D-5L, mortality, and complications, respectively. Results:Among 2,640 patients with an extracapsular hip fracture, 2,014 patients were treated with a long cephalomedullary nail and 626 patients with a short cephalomedullary nail. The adjusted mean difference in EQ-5D-5L in patients treated with a long and short cephalomedullary nail was 0.02 (95% CI -0.01 to 0.05; p = 0.144). The adjusted hazard ratio associated with treatment with a short cephalomedullary nail compared with a long cephalomedullary nail for mortality was 0.96 (95% CI 0.70 to 1.30; p = 0.772); reoperation 0.97 (95% CI 0.54 to 1.76; p = 0.919); fixation failure 1.20 (95% CI 0.47 to 3.06; p = 0.710); peri-implant fracture 0.97 (95% CI 0.30 to 3.17; p = 0.959); surgical site infection 1.06 (95% CI 0.60 to 1.86; p = 0.838); and blood transfusion 0.52 (95% CI 0.37 to 0.72; p < 0.001). Conclusion:Patients treated with long and short cephalomedullary nails for extracapsular hip fractures experienced a similar recovery in QoL. The implants had similar risk profiles in terms of mortality and surgical complications, although the risk of blood transfusion was higher after treatment with a long cephalomedullary nail. Surgeons may choose between long and short cephalomedullary nails according to the fracture type and patient factors in the knowledge that both implants provide similar outcomes.

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.

The 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 point 1,2 . We utilised a 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 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. 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% trauma is treated within Trauma Units (TUs) however, per unit, Major Trauma Centres (MTCs) treat approximately 43% more patients. 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. The 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.

INTRODUCTION:The initial assessment of pregnant women presenting with significant injuries is more complicated than that of non-pregnant women because of physiological and anatomical changes, and the presence of the fetus. The aim of this study was to determine whether guidelines for the early management of severely injured pregnant women exist, which aspects of assessment/management they cover and to what extent there is national consistency. METHODS:A freedom of information request was submitted to 125 acute National Health Service trusts in England and six in Wales. The trusts were asked to confirm whether they have a guideline for the management of major trauma in pregnant women presenting to the emergency department and what the guidelines were. RESULTS:In total, 96.2% of trusts responded, of which 19% have a specific guideline and 7.9% have a generic guideline for assessing pregnant women in the emergency department, irrespective of injury severity. Of the responding trusts, 19.8% have a protocol that specifies when an obstetric trauma call should be put out by the emergency department and when a pregnant woman should be transferred to a major trauma centre for definitive management. Our results found that 69.8% routinely call obstetrics or gynaecology to the trauma call compared with 36.5% calling paediatrics. CONCLUSIONS:The heterogeneity evident across trusts necessitates the establishment of national guidelines for the assessment of pregnant women with major trauma to standardise communication and delivery of care.

Introduction: Limb reconstruction surgery (LRS) has a wide range of clinical applications within orthopaedic and trauma surgery. We sought a consensus view from limb reconstruction healthcare practitioners across the United Kingdom to help guide research priorities within LRS. Our aim is to guide future clinical research in LRS, and assist healthcare practitioners, clinical academics, and funding bodies in identifying key research priorities to improve patient care. Materials and methods: A modified Delphi approach was used; it involved an initial scoping survey and a 2-round Delphi process to identify the consensus research priorities in both adult and paediatric LRS. Participants were asked to rank approved submitted questions according to perceived importance on a 5-point Likert scale, where 1 represented lowest importance and 5 indicated highest importance. Mean scores were calculated to identify a consensus of the top ten research priorities for adult and paediatric LRS. Results: One hundred and fifteen participants primarily from across the United Kingdom working in LRS contributed to the modified Delphi process. Participants ranked and then re-ranked the presented research topics in terms of perceived importance. This led to the identification of a top ten research priorities in both adult and paediatric LRS, respectively, based on the collective responses of LRS practitioners. The highest-ranked questions in both adult and paediatric practice related to how to best assess and record patient-reported outcome measures (PROMs) in LRS patients. Other priorities included the effectiveness of specialist physiotherapy, the use of patient-focused psychological support, and the use of various operative management strategies for infection and limb length discrepancies. Conclusion: We present a consensus-driven research priority study that outlines the key research topics and themes determined by healthcare professionals within LRS in the United Kingdom. Clinical significance: These questions will assist funding bodies in prioritising where research funding may be best utilised and help drive future improvement in patient care.

Patella fractures are uncommon injuries but in frail patients they may confer significant morbidity. Tension band metallic wiring (TBW) is frequently employed to manage these injuries yet complication rates are high. Up to one-third of patients require reoperation. In the frail host especially, patella fractures can result in significant functional impairment impacting on independence. Using the PRISMA guidelines, this systematic review interrogates the literature on patella fractures in the frail host. The evidence was found to be minimal and of low quality, comprising only eight cohort studies or case series. Sample sizes were small; in half of the included studies, 16 participants or less were included. 2493 patients were included from all extracted studies. The average age of patients was 71 years old with 60.5 % being female. AO/OTA 34-C2/3 fractures were the most common fracture patterns, comprising 41 % of patients. Current literature suggests that computed tomography (CT) scanning pre-operatively is appropriate. Marked heterogeneity was found in operative strategy; both metallic and non-metallic implants were investigated but metallic TBW and cerclage were the most prevalent techniques. Only one study investigated non-operative treatment. More than one in four patients (26.59 %) required reoperation and over one in five patients (22.53 %) suffered hardware complications. Average range of movement achieved was 121.28° +/- 13° but the investigation of other outcome measures was inconsistent. Further investigation into both patella fractures and, more specifically patella fractures in the poor host, is warranted. Nevertheless, due to its limited incidence, a multicentre approach is required and should be considered a priority for the orthopaedic community.

Aims: Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods: This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact: The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) ‘non-complex fracture’ recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027. Cite this article: Bone Jt Open 2024;5(3):184–201.

Background Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients. Methods We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals. Results We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain. Conclusions We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

INTRODUCTION:Trauma accounts for 20% of deaths in pregnant women. Injury characterisation and outcome in pregnant women following trauma is poorly described. To understand and inform optimum care of this key injury population, a study was conducted using the Trauma Audit Research Network (TARN) database.METHODS:In total, 341 pregnant and 26,774 non-pregnant female patients aged 15 to 46 years were identified for comparison from the TARN database. Mortality, cross-sectional imaging, blood product administration and EQ-5D scores were compared between the two groups. Mechanism of injury, Injury Severity Score (ISS) and mortality rate before and after the creation of regional trauma networks were reported for pregnant patients.RESULTS:Pregnancy was recorded in 1.3% (341/27,115) of included patients, with the most common cause of injury being road traffic collisions. A reduction in crude maternal mortality was observed over the course of the study period (7.3% to 2.9%). Baseline mean EQ-5D (0.47) and EQ-VAS (54.08) improved to 0.81 (p < 0.001) and 85.75 (p = 0.001), respectively, at 6 months following injury.CONCLUSION:The incidence of trauma in pregnancy is small and mortality in injured pregnant women decreased over the study period. Pregnant patients have significantly improved patient-reported outcome measures 6 months after injury although this is limited in impact because of poor response rates and outcome reporting. Construction and validation of tools aiding in outcome reporting will help considerably in understanding further gains in the care of pregnant women.

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.

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.

AimsAnkle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.MethodsA modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS).ResultsIn the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures.ConclusionA mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.Cite this article: Bone Jt Open 2024;5(3):236–242.

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 hours 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 hours (95%CI 4.83–10.36; p<0.001). 42.41% of anticoagulated patients received surgery within 36 hours (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 -4.48–0.887; 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 hours 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.

Approximately 20% of patients sustaining a fragility femur fracture use an anticoagulant, and over 30% use an antiplatelet medication, both of which can result in surgical delay. Previously confined to fractures of the proximal femur, performance assessment, outcome and surgical delay is now assessed for all fractures of the femur in older patients, including those involving implants. This narrative review draws together all literature pertaining to anticoagulation and antiplatelet management in older patients with a fracture of the femur to address 5 key points: prevalence of anticoagulant and antiplatelet use; analysis of management protocols; collation of national guidelines; comparison of perioperative management; timing of surgery and perioperative outcomes.Our review found that the prevalence of fragility femur fracture patients taking anticoagulant and antiplatelet medication ranges from 20-40% and 25-35% respectively. More anticoagulated patients are taking direct oral anticoagulants compared to vitamin k antagonists with growing implications for variation in practice and delays to surgery.Several national guidelines exist although these are characterised by marked variation, there is little standardisation, and none are generalised across all fragility femur fractures.Expedited surgery within 36 hours of admission in patients taking an anticoagulant or antiplatelet medication is safe and has been demonstrated in fractures of the proximal femur across many small number studies although no such evidence exists in non-proximal femur fractures despite this population sharing similar characteristics. There is a need for all fractures of the femur in older people to be considered when researching and assessing performance in this population to prevent needless variation and delay.

Introduction: Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery. Methods: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged >= 60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery. Results: Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219). Conclusions: Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.

The effective management of older patients with fragility fractures of the femur remains central to modern trauma care. Processes of assessment and communication alongside means of identifying poor performance are vital to improving care in this population. The National Hip Fracture Database (NHFD) now contains around 1 million cases and has evolved over time to reflect contemporary practices in the care of older injured patients. The NHFD is in a unique position to inform hip fracture care and the wider global management of injured older patients. This report provides an update and details the processes within the NHFD, the scope, lessons learned and highlights future direction.