Summary Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0.83, 95% CI 0.63–1.09; p=0.18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1.91, 1.06–3.44; p=0.0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0.82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0.41) and sepsis (seven [1%] vs six [1%]; p=0.79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians’ Services Incorporated.

Objective: Postoperative readmissions are frequent in vascular surgery patients, but it is not clear which factors are the main drivers of readmissions. Specifically, the relative contributions of patient comorbidities vs those of operative factors and postoperative complications are unknown. We sought to study the multiple potential drivers of readmission and to create a model for predicting the risk of readmission in vascular patients. Methods: The 2012-2013 American College of Surgeons National Surgical Quality Improvement Program data set was queried for unplanned readmissions in 86,238 vascular patients. Multivariable forward selection logistic regression analysis was used to model the relative contributions of patient comorbidities, operative factors, and postoperative complications for readmission. Results: The unplanned readmission rate was 9.3%. The preoperative model based on patient demographics and comorbidities predicted readmission risk with a low C index of .67; the top five predictors of readmission were American Society of Anesthesiologists class, preoperative open wound, inpatient operation, dialysis dependence, and diabetes mellitus. The postoperative model using operative factors and postoperative complications predicted readmission risk better (C index, .78); postoperative complications were the most significant predictor of readmission, overpowering patient comorbidities. Importantly, postoperative complications identified before discharge from the hospital were not a strong predictor of readmission as the model using predischarge postoperative complications had a similar C index to our preoperative model (.68). However, the inclusion of complications identified after discharge from the hospital appreciably improved the predictive power of the model (C index, .78). The top five predictors of readmission in the final model based on patient comorbidities and postoperative complications were postdischarge deep space infection, superficial surgical site infection, pneumonia, myocardial infection, and sepsis. Conclusions: Readmissions in vascular surgery patients are mainly driven by postoperative complications identified after discharge. Thus, efforts to reduce vascular readmissions focusing on inpatient hospital data may prove ineffective. Our study suggests that interventions to reduce vascular readmissions should focus on prompt identification of modifiable postdischarge complications.

Infectious complications dominate the reasons for unplanned 30-day readmissions in vascular surgery patients. We have identified preoperative, operative, and postoperative risk factors for these infections with the goal of reducing these complications and thus readmissions. Expected patient risk factors, such as diabetes, obesity, renal insufficiency, and cigarette smoking, were less important in predicting infectious complications compared with operative time, presence of a preoperative open wound, and inpatient operation. Our findings suggest that careful operative planning and expeditious operations may be the most effective approaches to reducing infections and thus readmissions in vascular surgery patients.

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