Gabriella Schreiner

OBJECTIVES: To determine if implementation of the HIP ATTACK protocol for hip fracture patients decreased delays in surgical fixation or postoperative mobilization. The primary hypothesis was that implementation of the HIP ATTACK protocols would improve time to surgery and time to mobilization. METHODS: Design: This was a retrospective review of patients who underwent hip fracture surgery between January 2011 and January 2021. Setting: A single academic institution where HIP ATTACK protocols were implemented in September 2016. Patient Selection Criteria: Patients >50 years undergoing surgery for treatment of hip fractures (AO 31A1.2-3, 31A2-3, 31B1-3, 32A-C). Outcome Measures and Comparisons: Time of diagnosis defined as the time of the initial presenting radiograph and time of mobilization defined as the time the patient stood at edge of bed with physical therapy (PT) were determined. Average values before and after implementation of the HIP ATTACK protocol were compared using a Student t test with a P = 0.05 set as the level of significance for each. RESULTS: A total of 781 patients were included in the analysis. There were 395 patients who had surgery before September 2016 (average age, 79 years; range 50–102 years; 267 women and 187 men), and 386 patients who were operated on after HIP ATTACK implementation (average age, 77 years; range 50–102 years; 232 women and 95 men). Compared with prior years, implementation of HIP ATTACK was associated with decreased time from diagnosis to surgery by an average of 8 hours (30 vs. 22 hours, P < 0.0001) and decreased time from surgery to PT evaluation by an average of 3 hours (30 vs. 27 hours, P = 0.049). Time from surgery to mobilization was not significantly different before and after HIP ATTACK implementation (59 vs. 58 hours, P = 0.63). CONCLUSIONS: Implementation of the standardized HIP ATTACK protocol by a multidisciplinary team was associated with improvement in time to surgery and PT evaluation. A standardized, multidisciplinary protocol can minimize delay in caring for patients with hip fractures and is critical in limiting morbidity and mortality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To perform breakeven analysis to assess the cost‐effectiveness of performing lateral extra‐articular tenodesis (LET) at the time of hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) in high‐risk patients. Methods: Baseline costs for ACLR, ACLR with LET (ACLR‐LET), revision ACLR, and initial failure rate were collected from the literature. Two initial failure rates following hamstring autograft ACLR without LET in high‐risk patients were used based on a previous study: the rate of revision surgery (11%) and the rate of clinical failure due to rotatory instability (40%). Breakeven economic analysis was used to assess the cost‐effectiveness of adding LET to primary ACLR. To account for the variability in cost, initial failure rates, and procedural differences across institutions, a wide range of values were used to calculate the absolute risk reduction (ARR) and number needed to treat (NNT) to achieve cost‐effectiveness. Results: Assuming primary ACLR cost of $20,840, ACLR‐LET cost of $27,405, and revision ACLR cost of $35,205, primary LET is cost‐effective at initial failure rates exceeding 18.7% (ARR = 0.187, NNT = 5). Assuming a 40% failure rate, LET is cost‐effective when revision surgery costs are greater than $16,412 (ARR = 0.400, NNT = 3) or when primary ACLR‐LET costs less than $39,422 (ARR = 0.400, NNT = 3). When assuming a failure rate of 11%, LET is cost‐effective when revision surgery costs exceed $59,700 (ARR = 0.110, NNT = −9) or when primary ACLR‐LET is no greater than $24,712 (ARR = 0.110, NNT = 10). Conclusions: Primary LET is a cost‐effective intervention for a wide range of primary and revision surgery costs according to this breakeven economic analysis. Using surgical cost estimates from literature, LET is cost‐effective when the initial failure exceeds 18.7%, or when revision surgery exceeds $16,412, which is greater than reported in current literature, thus indicating the clinical and economic benefits of primary LET in high‐risk patients undergoing hamstring autograft ACLR. Level of Evidence: Level IV, economic analysis.