A. L. Neuwirth1, M. G. Neuwirth1, R. N. Stitzlein1, R. R. Kelz1, S. Mehta1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA
Introduction: Intertrochanteric (IT) hip fracture fixation can be accomplished using either extramedullary (sliding hip screw) or intramedullary implants. Operative fixation techniques for hip fractures are taught with graduated levels of responsibility and involvement for the residents. Given the substantial morbidity and mortality associated with hip fractures in the elderly, understanding the effect of resident participation is important both to mitigate risk and to best prepare the next generation of surgeons. The goal of this study was to determine the effect of resident participation on outcomes in the treatment of IT hip fractures.
Methods: Patients who underwent operative treatment for IT hip fractures with either extramedullary (CPT 27244) or intramedullary (CPT 27245) fixation were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients were grouped and analyzed according to surgical fixation type and status of resident participation (RP) for the procedure. Primary outcomes were death and serious morbidity, secondary outcomes included operative time, total anesthesia time, hospital length of stay and time to discharge. Non-parametric analysis was performed using Chi-squared and Wilcoxon ranked sum tests, as well as multivariate logistic regression analysis to examine the association between RP and significant outcomes.
Results: In 8,384 patients who underwent IT hip fracture fixation, data for RP was available for 21% of all cases (n=1764), with a rate of 31.3%. Residents at the PGY4 level most frequently assisted (26.9%). For all IT hip fractures, there were no statistically significant differences in 30-day mortality (7.8% vs 6.3%, p=.264), morbidity (43.2% vs 44.9%, p=.506) or overall death or serious morbidity (49.1% vs 48.1%, p=.699) in the RP and non-RP groups. The RP group did demonstrate a significant increase in some secondary outcome parameters (see Table). There was no significant difference in overall death or serious morbidity rate when EM (42.9% vs 47.6%, p=.296) and IM (51.8% vs 48.4%, p=.271) fixation were analyzed independently.
Conclusion: RP in IT hip fracture fixation was not associated with an increase in morbidity and mortality for either EM or IM fixation. RP was associated with increased operative and anesthesia times in both EM and IM fixation, and with increased length of stay and time to discharge following operation in the IM group. Patients with IT hip fractures are at high risk for perioperative complications regardless of RP. While attending supervision is necessary, residents can and should be involved in the care of these patients without concern that resident involvement negatively impacts perioperative morbidity and mortality.
