48 h for femur fracture treatment: are we choosing the wrong quality index?

Background: In the last 10 years, the rate of femur fractures treated within 48 h from trauma has been introduced as a performance index for hospital management in Italy. Literature showed a significant indirect correlation between early treatment and mortality/comorbidity. The aims of early treatment are pain management and reduction of time to ambulation. The purpose of this study is to evaluate whether early treatment has reduced time to ambulation in femur fracture.

Materials And Methods: All patients admitted to two level I trauma centers with proximal femoral fracture between 1/1/2017 and 31/12/2017 were included in this study. Exclusion criteria were patient age younger than 65 years, death before surgery, and nonsurgical treatment. The following data were collected: age, gender, date and time of admission to emergency department, height, weight, body mass index (BMI), type and side of fracture, American Society of Anesthesiologists (ASA) score, date and time of surgery, surgical time, length of hospitalization, death during hospitalization, time from surgery to physiotherapy start, and time from surgery to first walking day.

Results: The study sample resulted in 660 patients. Mean age was 82 years, 64 % were female, mean BMI was 24 kg/m, mean ASA score was 2.7, and 42 % were medial fractures. Mean time from admission to surgery was 95 h; 49.8 % were treated within the first 48 h. Mean time from surgery to physiotherapy start was 2 days, 21 % were not able to walk during hospitalization, time from surgery to first walking day was 5 days, and mean hospitalization time was 15 days. Early surgery was significantly (p = 0.008) associated with the probability of ambulation recovery during hospitalization. No association (p = 0.513) was found between early surgery and time in bed without walking.

Conclusions: Early surgery in femur fracture became a priority in the health system. However, according to our data, although 51 % of patients were treated within the first 48 h, time from surgery to physiotherapy start (2 days) was still too long. Furthermore, time from surgery to first walking day was 6 days, longer than in most published papers. These data suggest that the performance index (rate of femur fractures treated within 48 h) may be improved by changing it to rate of femur fractures surgically treated with return to walking in 96 h.

Level Of Evidence: Level 4 (retrospective study).