Efficacy of a multidisciplinary care protocol for the treatment of operated hip fracture patients

To assess the effects of a multidisciplinary care protocol on cost, length of hospital stay (LOS), and mortality in hip-fracture-operated patients over 65 years. Prospective cohort study between 2011 and 2017. The unexposed group comprised patients who did not receive care according to the multidisciplinary protocol, while the exposed group did. Variables analyzed were demographics, medical comorbidities, treatment, blood parameters, surgical delay, LOS, re-admissions, mortality, and a composite outcome considering in-hospital mortality and/or LOS > 10 days. We performed a Poisson regression and cost analysis. The cohort included 681 patients: 310 unexposed and 371, exposed. The exposed group showed a shorter surgical delay (3.0 vs. 3.6 days; p < 0.001), and a higher proportion received surgery within 48 h (46.1% vs. 34.2%, p = 0.002). They also showed lower rates of 30-day readmission (9.4% vs. 15.8%, p = 0.012), 30-day mortality (4.9% vs. 9.4%, p = 0.021), in-hospital mortality (3.5% vs. 7.7%; p = 0.015), and LOS (8.4 vs. 9.1 days, p < 0.001). Multivariable analysis showed a protective effect of the protocol on the composite outcome (risk ratio 0.62, 95% CI 0.48–0.80, p < 0.001). Hospital costs were reduced by EUR 112,153.3. A multidisciplinary shared care protocol was associated with a reduction in the LOS, surgical delay, 30-day readmissions, and in-hospital and 30-day mortality, in hip-fracture-operated patients.

Is There a “Weekend Effect” in Intertrochanteric Fracture Surgery?

<b><i>Introduction:</i></b> Numerous studies reported poorer outcomes for patients who were admitted at weekends or off-hour, which relates to the underlying concept called the “weekend effect.” We aimed to assess the effect of adverse outcomes in older patients with intertrochanteric fracture surgery. <b><i>Methods:</i></b> A retrospective cohort study of patients aged ≥65 years with intertrochanteric fracture surgery. Data were collected from computerized medical records and all patients had a long-term follow-up. The association between weekend effect with adverse outcomes and factors for all-cause mortality was studied by 3-group comparison, Spearman and partial correlation analysis, univariate analysis, and multivariate Cox proportional-hazard model. <b><i>Results:</i></b> Our results showed no evidence supporting the existence of a weekend effect on adverse outcomes, including mortality rates (<i>p</i> = 0.950, log-rank), length of hospital stay, total hospital costs, rate and volume of transfusion, visual analog scale score, Harris Hip Score, and specific complications (all <i>p</i> &#x3e; 0.05), except for an average of 0.5 days longer surgical delay found in patients admitted on Fridays relative to other days (<i>p</i> = 0.013). Instead, only age group (with a 10-year interval, HR 1.43, 1.28–1.59 95% CI, <i>p</i> &#x3c; 0.001) and surgical delay (HR 1.05, 1.02–1.07 95% CI, <i>p</i> &#x3c; 0.001) were identified as significantly associated with all-cause mortality. <b><i>Conclusions:</i></b> Older patients with intertrochanteric fracture surgery have similar mortality and adverse outcomes rates when admitted on weekends or holidays compared with weekdays. Our findings suggest that collaborative multidisciplinary team care seems both effective and efficient in the management of older patients with intertrochanteric fractures on any day of the week.

855 OPTIMIZATION OF SURGICAL DELAY AFTER INDUCTION CHEMORADIATION FOR ESOPHAGEAL CANCER: 10 YEARS RETROSPECTIVE MULTI-CENTER STUDY

The treatment of esophageal cancer is in constant evolution. Most of the esophageal cancer receive induction chemoradiation therapy. Surgical delay has been studied but the optimal timing has not been clarified. Through the years, surgical delay has been modified by surgeons in our institutions, going from an average of 6 weeks delay to an average of 10 weeks delay. It is time to ask if this change has a real positive impact on our patient. Methods In this retrospective multi-center study, we combined data from two center in Quebec city that performs oncologic esophagectomy. The surgical delay went from 6 to 10 weeks around 2014. All surgeons changed their practice at that moment. We retrospectively analysed 5 years before and after the change of practice and created two cohorts of patients. Our primary outcome compared complete pathologic response rate. Our secondary outcomes were surgical complications, anastomotic leak, disease free survival and overall survival. Results Thirty-eight patients had surgery under 8 weeks (mean: 6 weeks) after their induction chemoradiation compared to 64 patients that had surgery after 8 weeks (mean: 10 weeks). There was no statistical significant difference between groups for the complete pathologic response (32% vs 25%, p = 0,16). Important complications were similar, with a rate of 24% vs 28% (p = 0,69). Anastomotic leaks were less frequent in the less than 8 weeks group, but no statistical significance was obtained (13% vs 27%, p = 0,14).No difference in the disease-free survival rate and overall survival rate was noted (DFS 40% vs 55% (p = 0,32), OS 38% vs 38% (p = 0,29)). Conclusion The treatment of esophageal cancer is in constant evolution, induction therapy and surgical technics involve over time. Surgical delay has no impact on complete pathologic response, complication and overall survival. There is no advantage to wait longer before surgery.

854 OPTIMIZATION OF SURGICAL DELAY AFTER INDUCTION CHEMORADIATION FOR ESOPHAGEAL CANCER: 10 YEARS RETROSPECTIVE MULTI-CENTER STUDY

The treatment of esophageal cancer is in constant evolution. Most of the esophageal cancer receive induction chemoradiation therapy. Surgical delay has been studied but the optimal timing has not been clarified. Through the years, surgical delay has been modified by surgeons in our institutions, going from an average of 6 weeks delay to an average of 10 weeks delay. It is time to ask if this change has a real positive impact on our patient. Methods In this retrospective multi-center study, we combined data from two center in Quebec city that performs oncologic esophagectomy. The surgical delay went from 6 to 10 weeks around 2014. All surgeons changed their practice at that moment. We retrospectively analysed 5 years before and after the change of practice and created two cohorts of patients. Our primary outcome compared complete pathologic response rate. Our secondary outcomes were surgical complications, anastomotic leak, disease free survival and overall survival. Results Thirty-eight patients had surgery under 8 weeks (mean: 6 weeks) after their induction chemoradiation compared to 64 patients that had surgery after 8 weeks (mean: 10 weeks). There was no statistical significant difference between groups for the complete pathologic response (32% vs 25%, p = 0,16). Important complications were similar, with a rate of 24% vs 28% (p = 0,69). Anastomotic leaks were less frequent in the less than 8 weeks group, but no statistical significance was obtained (13% vs 27%, p = 0,14). No difference in disease-free survival rate and overall survival rate was noted (DFS 40% vs 55% (p = 0,32), OS 38% vs 38% (p = 0,29)). Conclusion The treatment of esophageal cancer is in constant evolution, induction therapy and surgical technics involve over time. Surgical delay has no impact on complete pathologic response, complication and overall survival. There is no advantage to wait longer before surgery.

1549 Patient Perception on Hand Trauma Management Through a Plastic Surgery Trauma Clinic

Aim We assessed patient perceptions of hand trauma management through a plastic surgery trauma clinic. We also assessed effects of educating patients about outcomes of their condition on their desire to have prompt surgery. Method A prospective survey review was conducted at our plastic surgery trauma clinic. Patients included were those referred due to simple hand trauma. Any patients needing urgent admissions were excluded. An anonymous survey assessing patient perceptions before and after education about delay in surgery was distributed. Results Of 100 patients, there were mixed expectations regarding trauma clinic; 38% (n = 38) expect an operation, 32% (n = 32) expect no operation and 30% (n = 30) expect either option. 90% (n = 90) expect surgery within a week (50% n = 50) or within a day (40% n = 40); 10% expect it (n = 10) within a few weeks. After educating patients about no negative effects on their condition from surgical delay, 43% (n = 17) fewer patients desired surgery within a day, and 8% (n = 3) fewer patients desired surgery within a week. 190% (n = 19) more patients were willing to have surgery within a few weeks. 79% (n = 79) would rather come back at a guaranteed surgical slot than stay in hospital until a slot is available. 72% (n = 72) considered knowledge about long-term outcomes associated with surgical delay to influence their decision more than anaesthetic type (12% n = 12) and personal circumstances (16% n = 16). Conclusions If appropriate patients are assured that their condition will not be affected by surgical delay, fewer patients may stay in hospital with financial benefits of reduced bed occupancy and reduced covid risks.

Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders

Purpose Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair. Methods Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included. Results Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21–30 years. Conclusion Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment. Level of evidence Level IV.