Research Article: A new algorithm for hip fracture surgery

Date Published: February 8, 2012

Publisher: Informa Healthcare

Author(s): Henrik Palm, Michael Krasheninnikoff, Kim Holck, Tom Lemser, Nicolai Bang Foss, Steffen Jacobsen, Henrik Kehlet, Peter Gebuhr.


Treatment of hip fracture patients is controversial. We implemented a new operative and supervision algorithm (the Hvidovre algorithm) for surgical treatment of all hip fractures, primarily based on own previously published results.

2,000 consecutive patients over 50 years of age who were admitted and operated on because of a hip fracture were prospectively included. 1,000 of these patients were included after implementation of the algorithm. Demographic parameters, hospital treatment, and reoperations within the first postoperative year were assessed from patient records.

931 of 1,000 operative procedures were performed according to the algorithm, as compared to only 726 of 1,000 prior to its introduction (p < 0.001). After implementation of the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192 of 1,000 to 105 of 1,000 (p < 0.001). The rate of reoperations declined from 18% to 12% (p < 0.001 in a multiple Cox regression analysis), with a decline of 24% to 18% for intracapsular fractures and a decline of 13% to 7% for extracapsular fractures. The proportion of bed-days caused by reoperations was reduced from 24% of total hospitalization before the algorithm was introduced to 18% after it was introduced. It is possible to implement an algorithm for treatment of all hip fracture patients in a large teaching hospital. In our case, the Hvidovre algorithm both raised the rate of supervision and reduced the rate of reoperations. The reduced reoperation rate saved many hospital bed-days.

Partial Text

2,000 consecutive patients aged over 50 years were admitted to Hvidovre Hospital between September 2002 and July 2009 after having sustained a hip fracture, and they were prospectively included in a database. In March 2006, when 1,000 patients had been included, the algorithm was implemented prospectively for the next 1,000 patients.

Age, sex distribution, and cognitive function were similar in the 2 groups, whereas high ASA score and high NMS were commoner in patients who were treated before the algorithm (Table 1). Except for dislocation, all major reasons for reoperation were reduced, and the overall number of reoperations declined from 18% to 12%. From a multiple Cox regression analysis (Table 2), use of the algorithm statistically significantly reduced the risk of reoperation, as did higher patient age.

We found that an algorithm for the heterogeneous hip fracture patient population can be implemented and used by different surgeons in everyday clinical practice in a large teaching hospital. The overall reoperation rate was thereby reduced from a higher than average level to a slightly lower level than in the literature (Parker and Gurusamy 2005). The patients in our study were, however, unselected and consecutive, and therefore also included very fragile patients who would not normally be included in trials requiring written patient consent. The primary hospitalization was reduced from an average of 15 days to 12 days, but apart from the new algorithm, this might reflect a healthier patient population, improved perioperative treatment, and changed possibilities for discharge in the community. We therefore chose the conservative calculation described, but still found a drastic reduction in the rate of bed-days spent on reoperations. This improvement might be partly explained by an increased amount of attention in general during the early phase of implementation, but this could hardly be the reason during the whole study period.