Perioperative interventions, such as analgesia regimens, timing of surgery and type of anaesthesia, are recommended in clinical practice guidelines to address barriers to early mobilisation and optimise physical function outcomes. 

The aim of this systematic review and meta-analysis was to determine the effectiveness of perioperative interventions on achieving early mobilisation and improving physical function after hip fracture.

Twenty-eight studies were included in this systematic review and meta-analysis, in which participated a total of 8,192 patients with a fractured proximal femur and a mean age of 80 years. Interventions were grouped into six categories: analgesia, pathways and models of care, rehabilitation delivery modes, surgical protocols, nutritional supplements and clinical supervision.

The results of this study indicated that:

The authors concluded that many barriers to early mobilisation are potential amenable to perioperative interventions. The delivery of these perioperative interventions varies substantially between hospital sites and their impact on the ability to mobilise early postoperatively and restoration of physical function is not yet well understood. Future aetiologic studies are required to understand and model the causal mechanisms by which early mobilisation and physical function after hip fracture can be improved by perioperative interventions.

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Global rehabilitation needs have increased dramatically between 1990 and 2017, partially related to the aging global population. These increasing rehabilitation needs are not being met, with up to 50% of those requiring rehabilitation not able to access those resources, particularly in low- and middle-income countries.  In 2022, the World Health Organization (WHO) Rehabilitation Program established the World Rehabilitation Alliance (WRA) to support advocacy activities that promote access to rehabilitation.

The FFN became a member organization of the WRA in 2023 joining 4 of WRA’s workstreams: Research, Workforce, Primary Care and External Relations.  The mission of the FFN and WRA align very well to promote better rehabilitation access through changes in health policy that support development and implementation of rehabilitation resources. 

The WRA Research workstream has recently published an editorial highlighting the importance of Health Policy and Services Research in rehabilitation, which we share with FFN members here. We encourage you to review and disseminate this editorial within your local networks.

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The World Rehabilitation Alliance (WRA) is a WHO global network of stakeholders whose mission is to support the implementation of the Rehabilitation 2030 Initiative through advocacy activities. It focuses on promoting rehabilitation as an essential health service that is integral to Universal Health Coverage and to the realization of Sustainable Development Goal 3 Ensure healthy lives and promote well-being for all at all ages. The work of the WRA is divided into the following five workstreams: workforce, primary care, emergencies, external relations, and research.

Click here to learn more about WRA!

Mapping of fragility fracture care pathways and the subsequent identification and reporting of key performance indicators can reduce mortality and improve quality of life for patients, while at the same time reducing healthcare costs. 

This study aims to describe in detail the healthcare resources currently available in low- and middle-income countries in South and Southeast Asia and how hip fracture patients access these resources. This is the first step towards mapping service availability and readiness for hip fracture care in these countries, where care pathways for fragility fracture patients are poorly defined.

The study involved 98 representative hospitals from Malaysia, Thailand, Philippines, Sri Lanka and Nepal. The data for this study were collected from healthcare professionals and managers who completed an online questionnaire with information about pre-hospital care pathways, in-hospital care pathways, discharge information, post-discharge care pathways, and health and social care policies. 

Remarkable results of the study include the following:

• The cost of interventions was predominantly paid for by the individual, except in Sri Lanka and Thailand, where nearly all treatment was reported as being state-funded. 
• The median time between injury and arriving in hospital being less than 12 hours, with the exception of Nepal and the Philippines where the median time to hospital is more than a day.
• Most patients received surgery for their hip fracture, but the median time to surgery varied dramatically between countries, ranging from 2.5 days to 8.0 days.
• Pain scores were routinely recorded in most hospitals, but cognitive assessments were rarely recorded. Falls and bone health assessments were rarely made outside of Malaysia and Thailand.
• The majority of hospitals provided a mobility assessment on the first or second day after surgery, but there was notable variation in postoperative weight-bearing protocols.
• Most hospitals routinely offered patients follow-up appointments in the first six weeks after discharge.

According to Dr. Irewin Tabu, one of the authors of the study: ‘These data provide a baseline assessment of the current care pathways for hip fracture patients in these countries. As care pathways develop, service availability and readiness assessments can be used to track changes from this baseline. Future work is required to determine whether or not changes in pathways of care improve patient outcomes, with an emphasis on patient-reported health-related quality of life.' 

Read the article here.

Globally, there is important heterogeneity in nonoperative management of hip fractures, due to cultural, social, structural, and economic differences between healthcare systems. 

This is the first international survey of clinician perspectives on nonoperative hip fracture management. The authors explored the factors that influence clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people and aimed to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

This cross-sectional study involved 406 respondents (physicians, nurses, allied health professionals) from 51 countries and used a 28-item questionnaire about estimated epidemiology, medical reasons, external influences, and clinical decision-making regarding nonoperative management of hip fractures. 

The results of the study indicated that:
• The estimated proportion of patients presenting to hospital with hip fracture, and the estimated proportion receiving surgical management, were lower among LMIC respondents than those from HIC.
• The most commonly selected reasons for choosing nonoperative hip fracture management among HIC and LMIC clinicians were acute comorbidity, chronic comorbidity, and patient choice. 
• LMIC clinicians were more likely to select insufficient resources, socioeconomic status of the patient, and the patient’s ability to pay as common reasons of nonoperative hip fracture management than HIC clinicians.

In general, global heterogeneity seems to exist between HIC and LMIC clinicians regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. There seems to be some agreement among HIC and LMIC clinicians on factors such as the presence of acute and chronic comorbidities, type of hip fracture pattern, use of risk stratification tools, and patient thoughts and wishes.

Dr Lynn McNicoll, one of the authors, stated: ‘There is considerable debate on the comparative clinical outcomes for operative and nonoperative hip fracture management. Continued research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people.' 

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