Title : Complication and mortality rates following Neck of Femur (NOF) fracture surgery: Does SHO involvement increase risk?
Abstract:
Background: Concerns are frequently raised that increased operative exposure for Senior House Officers (SHOs) in neck of femur (NOF) fracture surgery could compromise patient safety. This service evaluation examined whether SHO-performed NOF fracture operations were associated with higher complication or mortality rates than operations performed by a registrar or consultant, and whether operative time was itself a risk factor, benchmarked against national mortality standards.
Methods: Operation notes for NOF fracture operations were reviewed (n=963 cases with complete clinical data). Inpatient falls (n=6), pathological fractures (n=1) and total hip replacements (n=2) were excluded, leaving 953 cases. Cases were classified by primary surgeon as SHO or non-SHO (registrar or consultant) and by procedure (hemiarthroplasty, dynamic hip screw [DHS], intramedullary [IM] nail, cannulated hip screws [CHS]). Outcomes were any recorded complication at any time and 90-day mortality. Chi-square/Fisher's exact tests compared proportions; Welch's t-test compared surgical time; multivariable logistic regression assessed the independent effect of SHO status and surgical time on each outcome, adjusting for ASA grade and age.
Results: Overall, SHO-performed cases had a significantly lower complication rate than non-SHO cases (12.8% vs 19.7%, p=0.043), with no significant difference in 90-day mortality (13.4% vs 16%, p=0.463). SHOs took significantly longer for hemiarthroplasty and DHS (both p<0.001) but not IM nail or CHS. Surgical time itself showed no association with complications (65.4 vs 65.5 minutes, p=0.966). Case-mix (ASA grade, age) was near-identical between groups. On multivariable logistic regression adjusting for ASA grade, age and surgical time, SHO status remained associated with significantly lower odds of complications (OR 0.58, 95% CI 0.36–0.94, p=0.028) and showed no significant association with mortality (OR 0.82, 95% CI 0.5–1.34, p=0.421). Overall cohort 90-day mortality was 15.4% (147/953), higher than typical published 90-day benchmarks (~10–12%) and the national 30-day NHFD average (~6–7%), consistent with a heavily comorbid case-mix (82% ASA grade ≥3).
Conclusion: There is no evidence that SHO involvement in NOF fracture surgery increases complication or mortality rates; if anything, SHO-performed cases showed fewer complications, including after adjustment for patient frailty. Operative time was not an independent predictor of complications or mortality. The cohort's overall mortality exceeds typical national benchmarks, most plausibly reflecting case-mix rather than surgeon grade, and warrants comparison against the unit's risk-adjusted NHFD submission.
